306000502-5-19-2021-22-AS-SSAS-C3RVAF-20210607161554

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 306000502
Report Date: 05/19/2021
Date Signed: 05/19/2021 01:52:07 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/11/2021 and conducted by Evaluator James August

PUBLIC

COMPLAINT CONTROL NUMBER: 22-AS-20210111154217

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: 70	DATE:	05/19/2021
		UNANNOUNCED	TIME BEGAN:	01:12 PM
MET WITH:	Glen Goldmsith, Executive Director		TIME COMPLETED:	01:44 PM

ALLEGATION(S):

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Staff are not protecting a resident's privacy

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jim August made an unannounced visit to conclude a complaint investigation. LPA identified himself and discussed the purpose of the visit with Executive Director (E.D.) Glen Goldsmith.
The initial 10-day facility visit was completed on January 14, 2021.
The investigation into the allegation that facility staff are not protecting resident’s privacy revealed the following:
On January 14, 2021 LPA August interviewed E.D. Goldsmith who stated that resident 1 (R1) had wandering behaviors and would enter resident 2 (R2)’s bedroom once or twice a week. Staff would redirect R1 out of R1’s room. Goldsmith requested that R1 keep her room door closed and locked, however R1 wanted to keep her door open.
On January 29, 2021, LPA August interviewed R2 who stated that R1 was constantly coming in her room, even when the door was closed. R2 stated that R1 would violate her privacy several times a week.
Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210111154217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2021

NARRATIVE

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R2 stated that on occasion staff would forget to close or lock her door when exiting the room and R1 would then enter her room. R2 stated that she was bed bound and unable to get up and close the door after staff left it open.

On May 4, 2021 LPA August interviewed resident 3 (R3). R3 stated that R1 would wander the hallway of resident rooms and try and open each door. R3 would find R1 in his room 3 to 4 times a week for several months.

Based on LPA's observations and conducted interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

The following deficiency is a violation of Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted along with appeal rights.

SUPERVISOR'S NAME: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC9099 (FAS) - (06/04)

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Control Number 22-AS-20210111154217

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/19/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 05/19/2021 Section Cited CCR 87468.2(a)(1)	1 2 3 4 5 6 7	Additional Personal Rights of Residents in Privately Operated Facilities...To have a reasonable level of personal privacy in accommodations...This requirement was not met as evidenced by: Based on interviews with residents and staff, the facility did not ensure that residents are afforded a reasonable level of personal privacy.	1 2 3 4 5 6 7	Licensee states they will ensure that all staff are trained on resident privacy and ensuring that doors are kept closed and locked if requested.
	8 9 10 11 12 13 14	This poses a potential health, safety, and/or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Sheila Santos	TELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: James August	TELEPHONE: 714-703-2853
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2021

LIC9099 (FAS) - (06/04)

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