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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 10/06/2022
Date Signed: 10/06/2022 03:26:31 PM


Document Has Been Signed on 10/06/2022 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868



FACILITY NAME:NEW HORIZON LODGE, INC.FACILITY NUMBER:
306000502
ADMINISTRATOR:GLEN E GOLDSMITHFACILITY TYPE:
740
ADDRESS:8541 CERRITOS AVENUETELEPHONE:
(714) 821-5781
CITY:STANTONSTATE: CAZIP CODE:
90680
CAPACITY:120CENSUS: 68DATE:
10/06/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Glen GoldsmithTIME COMPLETED:
03:35 PM
NARRATIVE
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Licensing Program Analyst (LPA) Jerome Haley conducted an unannounced case management visit at New Horizon Lodge. LPA was greeted, and explained the reason for the visit. LPA Haley met with Administrator (AD) Glen Goldsmith.

The purpose of today's visit was to conduct a Case Management visit to discuss an Unusual Incident Report (LIC 624) that was sent to the Orange County Adult and Senior Care Program Regional Office October 6, 2022 that involved Resident 1 (R1).

During the visit LPA Haley interviewed AD Goldsmith and R1 about the incident. LPA Haley received copies of R1's Physician's Report, Individualized Service Plan (ISP), and California Assisted Living Waiver ISP.

Deficiencies are being cited during today's Case Management visit.

An exit interview was conducted and a copy of this report, LIC809D, LIC811, and appeal rights were provided.

SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/06/2022 03:26 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868


FACILITY NAME: NEW HORIZON LODGE, INC.
FACILITY NUMBER: 306000502

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/06/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/06/2022
Section Cited

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Basic Services - (f) Basic services shall at a minimum include: (1)Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c) "Care and supervision" means the facility assumes responsibility for... ongoing assistance with activities of daily living without which the resident's physical health, mental health,
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safety, or welfare would be endangered.

This requirement was not met as evidenced by: On 9/29/22 R1 left the facility without supervision and was gone for over an hour.This poses a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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