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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 01/13/2023
Date Signed: 01/13/2023 01:25:56 PM


Document Has Been Signed on 01/13/2023 01:25 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: 72DATE:
01/13/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Glen GoldsmithTIME COMPLETED:
01:40 PM
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This unannounced case management inspection is being conducted by Licensing Program Analyst (LPA) Sean Haddad for the purpose of following up on a self-reported incident report received in the Orange County Regional Office (OCRO) on 01/04/23 regarding a medication error involving Resident #1 (R1). LPA met with Administrator (AD) Glen Goldsmith and discussed the purpose of the inspection.

The incident report states that on 12/31/22, R1 received the wrong medication at bedtime, facility staff notified a doctor who advised facility staff to monitor R1 and report any changes, R1 was monitored, and additional training will be conducted to avoid future medication errors.

During today’s inspection, LPA conducted a health and safety check on R1, observed no health and safety issues, and observed R1 was in good health and good spirits. LPA inspected the medication room, observed it to be clean and organized, and observed no health and safety issues. LPA interviewed AD who confirmed the information in the incident report and provided the following information: the medication error involved R1 receiving their own medications at the wrong time; on that day, R1 received their AM medications in the morning but in the PM R1 was given the next day’s AM medications instead of their PM medications; the error was made by Staff #1 (S1); the facility notified the doctor and observed R1; there were no complications with R1 and the doctor did not recommend sending R1 to the hospital; and the facility is completely retraining S1. LPA reviewed training records showing that S1 began the retraining process on 01/05/23 and completed the process on 01/10/23.

Based on the information obtained during today’s inspection, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. See LIC809D. An exit interview was conducted and a copy of this report and appeal rights was discussed with and provided to facility representative.
SUPERVISOR'S NAME: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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 01/13/2023 01:25 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: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/14/2023
Section Cited

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87465 Incidental Medical and Dental Care. (a) … (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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During the inspection, Licensee provided proof that the staff at issue was retrained.

POC CLEARED.
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Based on interview and documents, the licensee did not ensure R1 received assistance with self-administered medications, which poses an immediate health and safety risk to persons 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: Armando J LuceroTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Sean HaddadTELEPHONE: (714) 335-7094
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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