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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306004330
Report Date: 04/12/2022
Date Signed: 04/13/2022 08:34:01 AM


Document Has Been Signed on 04/13/2022 08:34 AM - 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 IVFACILITY NUMBER:
306004330
ADMINISTRATOR:IMELDA AGUILAFACILITY TYPE:
740
ADDRESS:207 ISLANDIA DRIVETELEPHONE:
(714) 854-7568
CITY:PLACENTIASTATE: CAZIP CODE:
92870
CAPACITY:6CENSUS: 6DATE:
04/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Imelda AguilaTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Michelle Reed made an unannounced visit to the facility to conduct an Annual visit. Upon arrival LPA met with Staff Evangeline Javier. The focus of the visit was Infection Control. The facility was toured with Ms. Javier. Administrator Imelda Aguila arrived a short time later. The following was observed:

Covid signs were posted inside the facility and a sanitization station was set up by the front entrance. LPA's temperature was taken upon arrival and a sign in sheet was available. Facility has required Department postings. Restrooms observed contained soap and toilet paper. Paper towels were also available. Hand sanitizer, soap, wipes and gloves were present and in sufficient supply. The Licensee has at least a 30 day supply of PPE. LPA observed an outside visitation area with ample shading. There were six residents present. Five of the six are receiving hospice services. Administrator Certificate for Imelda Aguila expires 6/23. Social Distancing and masks were observed. Licensee has required Mitigation plan and Emergency Disaster Plan. Facility has emergency food and water supply. Facility has a secured cupboard for resident medication. Resident files were locked.

During the visit, LPA consulted with staff regarding the importance of maintaining a 30 day supply of PPE on site. Additionally, LPA advised the importance of masks and hand washing for staff and visitors. Administrator is reminded to review all Department PINS in regards to Masks, Staff and Resident Testing, Visitation, Dining, Group Activities, Non-essential services, Outings, New Admissions and Entertainment. No deficiencies noted during visit. An exit interview was conducted and a copy of this report was provided to Imelda Aguila.
SUPERVISOR'S NAME: Sheila SantosTELEPHONE: (714) 703-2857
LICENSING EVALUATOR NAME: Michelle ReedTELEPHONE: (714) 743-4958
LICENSING EVALUATOR SIGNATURE:
DATE: 04/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/12/2022
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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