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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004271
Report Date: 01/29/2020
Date Signed: 10/31/2022 07:07:04 PM


Document Has Been Signed on 10/31/2022 07:07 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 BOARD AND CAREFACILITY NUMBER:
306004271
ADMINISTRATOR:IMELDA AGUILAFACILITY TYPE:
740
ADDRESS:5652 CLUB VIEW DRIVETELEPHONE:
(714) 222-5210
CITY:YORBA LINDASTATE: CAZIP CODE:
92886
CAPACITY:6CENSUS: 6DATE:
01/29/2020
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Imelda Aguila, AdministratorTIME COMPLETED:
03:15 PM
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On 1/29/2020, at 1215 PM, Licensing Program Analyst (LPA) Kathrina Chin conducted an required annual visit. During the visit, LPA met with care givers Flordelina Gualta and Loida Bacus who notified Administrator Aguila of LPA's presence. Administrator arrived shortly after and provided a of the facility inside and out. The facilities fire clearance is for 6 non ambulatory residents and has a hospice waiver for (4). Currently (6) residents reside at the facility in which (2) residents are receiving hospice services. The facility serves residents with dementia, appropriate safety features such as delayed egress were observed and operational.

At 1 PM, a tour was provided of the facility, the following was observed; There is at least one week supply of nonperishable and 2 day supply of perishable food. LPA spoke with residents in care during todays visit.
There are appropriate furnishing for resident bedrooms with sufficient lighting. LPA observed restrooms had grab bars for each toilet and shower, in addition to non skid mats. Hot water temperature measures at 112.6

At 1:30 PM, LPA observed centrally store medications and to be inaccessible to residents in care and stored in a locked cabinet in the kitchen. Toxic chemicals are locked in cabinet in laundry room. Facility has a 610 posted. LPA discussed evacuation in the event of a disaster.

At 1:45 PM, Resident files were reviewed and contained a signed admission agreement and a medical assessment. There are no residents who have prohibited health conditions residing at the facility.

At 2-3 PM. Upon reviewing staff records LPA observed 20 hours of training annually including 8 hours of dementia training. Resident and staff files were reviewed and no concerns noted. LPA reviewed medications and centrally stored medications records.

No deficiencies were observed on this date as the facility remains in compliance. An exit interview was conducted, and copy of this report was given to Flordelina Gualta, facility representative.
SUPERVISOR'S NAME: Lori BertrandTELEPHONE: (714) 703-2840
LICENSING EVALUATOR NAME: Kathrina ChinTELEPHONE: (714) 703-2840
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2020
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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