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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 12/27/2022
Date Signed: 12/27/2022 01:14:50 PM


Document Has Been Signed on 12/27/2022 01:14 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: 73DATE:
12/27/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:35 AM
MET WITH:Alexsondra CarrilloTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA) Jerome Haley made an unannounced visit for the purpose of conducting a Case Management visit regarding Unusual Incident Reports (LIC 624) sent to the regional office. Both incident report were received December 16, 2022. LPA interviewed Wellness Coordinator Alexsondra Carrillo and spoke with Administrator (AD) Glen Goldsmith via telephone regarding the incident reports.

Regarding the first LIC 624 (incident date 12.14.22) LPA Haley received a copy of Resident 1's (R1) physicians report, and the information on R1's new dialysis center and the information the new transportation company taking R1 to his dialysis appointments. Regarding the second incident report (incident date 12.11.22) LPA Haley received copies of Resident 2s (R2): basic fact sheet, physicians report, and preplacement appraisal information. Further, LPA Haley reviewed the file for Staff 1 (S1) and received copies of the LIC 501 and a copy of Relias training completed by S1.


No deficiencies are being cited as a result of today's visit. An exit interview was conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Luz AdamsTELEPHONE: (714) 222-3821
LICENSING EVALUATOR NAME: Jerome HaleyTELEPHONE: 714-703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2022
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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