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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331800150
Report Date: 02/11/2025
Date Signed: 02/11/2025 01:39:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/01/2023 and conducted by Evaluator Mary Rico
PUBLIC
COMPLAINT CONTROL NUMBER: 56-AS-20230901090815
FACILITY NAME:NEW HORIZONSFACILITY NUMBER:
331800150
ADMINISTRATOR:PEREZ, MA TERESA VFACILITY TYPE:
740
ADDRESS:7550 RUDELL ROADTELEPHONE:
(951) 531-8048
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY:15CENSUS: 15DATE:
02/11/2025
UNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Facility Manager Eldalin De DeugdTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident sustained unexplained fracture while in care.
INVESTIGATION FINDINGS:
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On 2/11/2025 Licensing Program Analyst (LPA) Mary Rico conducted an unannounced visit to the facility to deliver complaint investigation findings for the above allegation. After introducing and identifying self, LPA met with Facility Manager Eldalin De Deugd to discuss the findings.

On September 1, 2023, the Department received a complaint with allegation of personal rights violation resulting in R1 sustaining injury (fracture). The Department investigation consisted of review of facility and other records, observations, and interviews with pertinent individuals.

Investigation revealed that on August 30, 2023, R1 went to local hospital due to right knee swelling. Per medical records, it was indicated that R1 sustained an unexplained fracture while in care.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 56-AS-20230901090815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: NEW HORIZONS
FACILITY NUMBER: 331800150
VISIT DATE: 02/11/2025
NARRATIVE
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 More specifically, diagnosis was acute displaced right distal femur fracture. Per interviews, facility staff denied there was a fall or other known trauma to explain the injury. According to physician doctor who treated R1 while at the hospital, R1’s age and medical condition made R1 more susceptible to the fractures. However, physician reported that some type of force or trauma was still necessary to cause the fracture. Though the exact mechanism of the injury cannot be established, a fall, drop or some other trauma during a transfer cannot be ruled out. According to the Osteoporosis Foundation website, fragility fractures result from low level or low energy trauma, such as a fall from standing height or less.

According to facility records, R1 was non-ambulatory, and wheelchair bound. R1 was confused, disoriented, and not able to indicate how injury occurred. In addition, Records revealed that R1 needed help with transferring from the bed to the wheelchair. R1 also needed assistance with bathing, showering, toileting, grooming, dressing, and feeding. R1 further needed assistance with medication management and administration. It was specifically indicated that R1 could not bear weight, kept legs in curled up position, and was resistant to straightening legs.

Based upon further review of R1 records, services such as care, supervision, and observation for changes in physical, mental, emotional, and social functioning was to be provided. However, the preponderance of evidence supports that facility staff failed to implement a care plan to address R1 needs. As a result, on or around August 30, 2023, while at the facility, R1 sustained an unexplained fracture.

The above allegation is found to be SUBSTANTIATED. A deficiency is being issued per California Code of Regulations, Title 22. A substantiated finding means that the allegation is valid because the preponderance of evidence standard has been met.

In addition, this violation posed an immediate Health and Safety risk to resident(s) in care. An Immediate Civil Penalty of $500 is being assessed. The licensee was also informed that a civil penalty may be assessed based on Health and Safety Code § 1569.49.

An exit interview was conducted where this report, LIC9099D, LIC421IM, and appeal rights were discussed and provided to the Facility Manager Eldalin De Deugd.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 56-AS-20230901090815
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: NEW HORIZONS
FACILITY NUMBER: 331800150
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/11/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2025
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4)Additional Personal Rights of Residents in Privately Operated Facilities(4) To care, supervision, and services. meet their individual needs.. delivered by staff.. sufficient in numbers, qualifications.. to meet their needs.This requirement is not met as evidenced by:
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The Administrator stated they conduct an in-service training for all staff members on the regulation cited. Administrator also stated they will send proof to LPA Rico.
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Based upon review of facility, records, observations, and interviews licensee failed to ensure that R1 was provided with care, supervision,services required. As a result, R1 sustained a fracture while at facility. This violation posed an immediate health and safety risk to residents in care.
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POC due date 2/12/2025
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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.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Mary Rico
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2025
LIC9099 (FAS) - (06/04)
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