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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800150
Report Date: 09/06/2023
Date Signed: 09/06/2023 01:52:58 PM


Document Has Been Signed on 09/06/2023 01:52 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507



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:
09/06/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Eldalin De Deugd- Facility ManagerTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ryan Gardner made an unannounced case management visit to conduct a Health and Safety check of the residents in care at the facility. LPA met with Facility Manager Eldalin De Deugd and explained the reason for the visit.

The Health and Safety check included overall observation of the facility inside, and outside, including food supply, medications, records, physical plant, and the residents in care.

LPA observed the following safety concern in Resident R1’s records review:

During document review LPA discovered that R1 was admitted to the facility on 11/1/2018. R1’s most recent resident appraisal, LIC 603A, was completed on 11/1/2018. R1’s most recent physician’s report, LIC602A, was completed on 1/16/2021. Based on R1’s medical diagnosis, R1 should have an updated LIC603A and LIC602A annually. The facility not completing an annual LIC603A and an LIC602A for R1 poses an immediate health, safety, or personal rights risk to persons in care.

Based on the observations made during today’s visit, one (1) deficiency was cited per Title 22, Division 6, of the California Code of Regulations.

An exit interview was conducted, and this report was discussed and provided to Facility Manager Eldalin De Deugd and, along with a copy of the appeal rights.

SUPERVISOR'S NAME: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
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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Document Has Been Signed on 09/06/2023 01:52 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
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: 09/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/07/2023
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia(c)Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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The licensee has agreed to read regulation 87705 entirely and send LPA a self-certified letter that the regulation was read and understood. The licensee has agreed to ensure R1 has the required assesments completed.
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Based on interview and document review, the licensee did not comply with the section cited above evidenced by not completing an annual medical assessment and reappraisal for Resident R1 which poses an immediate health, safety, or personal rights risk to persons in care.
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The licensee has agreed that moving forward all dementia care residents will have a medical assessment and reappraisal completed annually. The POC is due by 9/7/2023.

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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: Efren MalagonTELEPHONE: (951) 248-8222
LICENSING EVALUATOR NAME: Ryan GardnerTELEPHONE: (951) 836-3180
LICENSING EVALUATOR SIGNATURE:
DATE: 09/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/06/2023
LIC809 (FAS) - (06/04)
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