306000502-12-20-2022-22-AS-JHAY-CMAPKY-20221220102354

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 12/20/2022
Date Signed: 12/20/2022 10:24:35 AM

Document Has Been Signed on 12/20/2022 10:24 AM - 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 GOLDSMITH		FACILITY TYPE:	740
ADDRESS:	8541 CERRITOS AVENUE		TELEPHONE:	(714) 821-5781
CITY:	STANTON	STATE: CA	ZIP CODE:	90680
CAPACITY:	120	CENSUS: 72	DATE:	12/20/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:40 AM
MET WITH:	Glen Goldsmith		TIME COMPLETED:	10:35 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Jerome Haley arrived at the facility for the purpose of conducting a required one year infection control annual visit. LPA was greeted, granted entry by staff and explained the reason for the visit. Staff called the Administrator (AD) Glen Goldsmith who arrived and was present for the visit. AD Goldsmith has a current administrators certificate that expires 06/16/23. LPA Haley was pre screened and temperature checked upon entering the facility. There were 72 residents at the facility during the time of inspection The inspection began on the first floor of the facility. LPA Haley observed a locked medication room near the reception desk. LPA Haley observed mediation cart and two first aid kits with all the required items. The dining room and kitchen was clean and organized. LPA Haley observed a two day supply of perishable items and a seven day supply of nonperishable items in the kitchen. All knives and sharp objects were were safely stored. LPA observed a menu, and a list of residents on a special diet posted on the freezer next to the temperature logs. While touring the first floor of the facility, LPA observed the activities room and observed residents listening to music and exercising. A break room for facility staff was observed. LPA Haley tested the call light system and it tested operational. During the inspection of the second floor LPA observed the laundry room with plenty of clean linen. In the locked storage cabinets used to to store additional supplies of PPE: surgical mask, gowns, gloves, and N95 face mask were observed. On the second floor LPA Haley observed the maintenance room, and an additional activities room on the second floor for residents to enjoy. Continued on LIC809C

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

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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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
	VISIT DATE: 12/20/2022

NARRATIVE

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While inspecting resident rooms on both floors, all resident rooms observed had the necessary requirements. Resident bathrooms were in good repair and the hot water temperature was measured between 105 - 112.3 degrees Fahrenheit.

The exterior of the facility was clean and organized. Walkways were clear and free of tripping hazards. LPA observed several tables with plenty of sitting for the residents to enjoy while outdoors. No bodies of water observed.

LPA observed several fully charged and mounted fire extinguishers mounted on the walls on both floors of the facility.

No deficiencies are being cited as a result of todays visit. An exit interview was conducted and a copy of this report was provided to AD Goldsmith,.

SUPERVISOR'S NAME: Luz Adams	TELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome Haley	TELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2022

LIC809 (FAS) - (06/04)

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