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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004329
Report Date: 03/03/2022
Date Signed: 03/03/2022 02:43:52 PM


Document Has Been Signed on 03/03/2022 02:43 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 CARE IIIFACILITY NUMBER:
306004329
ADMINISTRATOR:IMELDA AGUILAFACILITY TYPE:
740
ADDRESS:5330 E. RURAL RIDGE CIRCLETELEPHONE:
(714) 998-7750
CITY:ANAHEIM HILLSSTATE: CAZIP CODE:
92807
CAPACITY:6CENSUS: 5DATE:
03/03/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Michelle SolomonTIME COMPLETED:
10:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility and explained the reason for the visit. Administrator Mel Aguila arrived during the visit. Administrator Virgilo Aguila has an administrator certificate expiring on 02/14/2023.

At 9:25 AM, LPA toured the facility with Caregiver Michelle Solomon. Administrator Mel Aguila joined the tour in progress. Facility has 5 residents in care during today's visit with 3 residents on hospice care. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. Facility appears clean and sanitary. All resident rooms had the required elements. At 9:35 AM, LPA observed unsecured vitamins in the unlocked caregiver room. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a hand written visitor sign in sheet/ questionnaire. Facility takes resident and staff temperatures daily. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food. LPA observed the shaded outside visitation area. Exit gates are self latching and unlocked. LPA observed the locked medication area. Facility does not use a medication administration record. Facility does a monthly audit of medications. Facility provides activities in the form of exercise and games. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed all resident files during the visit and all files have updated emergency information. All residents and all staff are vaccinated for Covid-19.
LPA consulted with Administrator regarding the importance of maintaining an ample supply of emergency food and water on-site at the facility.

The following deficiency is being cited per Title 22 Division 6 of the California Code of Regulations. This report, along with appeal rights, were discussed with the facility representative and a copy of this report was provided to the facility at exit.

SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 03/03/2022 02:43 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 BOARD AND CARE III
FACILITY NUMBER: 306004329

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/03/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
The following shall be stored inaccessible to residents with dementia:

Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed unsecured vitamins in the unlocked caregiver room. (Photos). This poses an immediate health and safety risk to persons in care.
POC Due Date: 03/04/2022
Plan of Correction
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Licensee to secure items and forward proof to LPA by POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 03/03/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/03/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2