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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.

SUPERVISORS NAME: Luz Adams
LICENSING EVALUATOR NAME: Jerome Haley
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


Created By: Jerome Haley On 10/06/2022 at 02:47 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
CCR
87464(f)(1)

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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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Administrator agrees to train all residents on the use of the sign in/out sheet and reasses all residents curently unable to leave unassisted for accuracy.

Proof of completion will be submitted to LPA Haley by Friday October 14, 2022.
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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 Adams
LICENSING EVALUATOR NAME:Jerome Haley
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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