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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306000502
Report Date: 02/25/2022
Date Signed: 02/25/2022 03:58:44 PM


Document Has Been Signed on 02/25/2022 03:58 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: 69DATE:
02/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Administrator Glen GoldsmithTIME COMPLETED:
04:05 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 an Unusual Incident Report (LIC 624) received from facility on 02/23/2022. LPA was greeted at the reception desk by Administrator Glen Goldsmith and explained the reason for the visit today. LPA interviewed AD Goldsmith and Staff 1 (S1) concerning the February 18 incident regarding Resident 1 (R1).

On 02/18/2022, R1 exhibited escalating inappropriate behavior of a sexual nature. The behavior was both physical and verbal, and it was directed towards some female staff and residents.

LPA Haley requested Resident 1's (R1) files. LPA reviewed and obtained copies of R1's: Basic Fact Sheet, Individualized Service Plan, Physicians Report, and Preplacement Appraisal Information (page 1).

LPA explained if further follow up is required, LPA Haley will return at a later date to continue follow up of this incident. No deficiencies cited at this time.
An exit interview was conducted with Administrator Goldsmith 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: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2022
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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