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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331800150
Report Date: 07/15/2024
Date Signed: 07/15/2024 03:04:17 PM

Document Has Been Signed on 07/15/2024 03:04 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:NEW HORIZONSFACILITY NUMBER:
331800150
ADMINISTRATOR/
DIRECTOR:		PEREZ, MA TERESA VFACILITY TYPE:
740
ADDRESS:7550 RUDELL ROADTELEPHONE:
(951) 531-8048
CITY:CORONASTATE: CAZIP CODE:
92881
CAPACITY: 15CENSUS: 14DATE:
07/15/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:25 AM
MET WITH:Licensee/Administrator Teresa PerezTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
NARRATIVE
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On 07/15/2024, Licensing Program Analyst (LPA) Melody Brown conducted an unannounced visit to the facility to commence a case management visit. LPA Brown was greeted and granted entrance by a staff member and LPA Brown met with Licensee/Administrator Teresa Perez. LPA Brown identified herself and discussed the purpose of the visit with Licensee/Administrator Teresa Perez. At the time of the visit, there were fourteen (14) residents, and five (5) staffs present.

During today's visit, LPA Brown observed Staff #8 (S8) and Staff #9 (S9) working at the facility and per documents review, LPA Brown noticed that S8 and S9 have criminal background clearance but S8 and S9 criminal background clearance were not transferred to the facility prior to their employment. Also, staff interviews and records review indicated that S8 started working at the facility on 06/16/2024 and S9 started working at the facility on 06/07/2024. Licensee/Administrator Teresa Perez was informed that deficiency will be issued. Also, Civil Penalty was assessed with the amount of $500.00 per individual and will continue to be assessed of $100.00 per day per citation until corrected for not transferring S8 and S9 criminal background clearance to the facility prior to employment.

In addition, during the tour of the facility, LPA Brown observed that Resident #1 (R1) has full bed rail and staff interview and records review indicated that R1's not on hospice and no exception report was submitted and approved by Community Care Licensing Division (CCLD) Adult and Senior Care (ASC) Regional Office. Deficiency will be issued. Moreover, LPA Brown observed Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #8 (R8), Resident #9 (R9), and Resident #10 (R10) with half bed rails but staff interviews and document review indicated that there are no written order from their physician indicating the need for half bed rail for mobility. Deficiency will be issued.

To add to that, during the review of R1's Medication Administration Record (MAR), LPA Brown observed that there's no record at the facility showing that staff are dispensing R1's medications per R1's physician's order since 07/01/2024. Deficiency will be issued.

**** Continuation in LIC809C ****

SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE: DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/15/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: NEW HORIZONS
FACILITY NUMBER: 331800150
VISIT DATE: 07/15/2024
NARRATIVE
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Furthermore, LPA Brown observed R1's Physician Report (form LIC602) does not have physician signature and signature date. Deficiency will be issued.

An exit interview was conducted where this report (LIC809), LIC809D, LIC421BG and Appeal Rights were discussed and provided to Licensee/Administrator Teresa Perez.
SUPERVISORS NAME: Efren Malagon
LICENSING EVALUATOR NAME: Melody Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 07/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/15/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/15/2024 03:04 PM - It Cannot Be Edited


Created By: Melody Brown On 07/15/2024 at 01:37 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HORIZONS
FACILITY NUMBER: 331800150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/09/2024
Section Cited
CCR
87465(a)(6)

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87465 Incidental & Medical Services (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance...(6) When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility. This requirement is not met as evidenced by:
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Licensee stated to train all staff in CCR 87465(a)(6) and submit proof of Training Log to LPA Brown at Plan of Correction (POC) due date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not updating Resident #1 (R1) Medication Administration Record (MAR) when dispensing R1 medications from 07/01/2024 to 07/15/2024 which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
07/16/2024
Section Cited
CCR87608(a)(5)(B)

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87608 Postural Supports (a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do...(5) Under no circumstances shall postural supports include tying, depriving, or limiting the use of a resident's hands or feet. (B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails. This requirement is not met as evidenced by:

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Licensee stated to remove R1's full bed rail and submit proof to LPA Brown on POC due date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above by having a full bed rail for Resident #1 (R1) and R1's not on hospice and no exception was submitted and approved to CCLD which poses an immediate health, safety or personal rights risk to persons in care.
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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 Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 07/15/2024 03:04 PM - It Cannot Be Edited


Created By: Melody Brown On 07/15/2024 at 01:54 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HORIZONS
FACILITY NUMBER: 331800150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/16/2024
Section Cited
CCR
87458(a)

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87458 Medical Assessment (a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment. This requirement is not met as evidenced by:
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Licensee stated to submit a copy of R1's completed Physician Reports with Physician Signature Date to LPA Brown on Plan of Correction (POC) due date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above
by not having a completed Physician Report with Physician Signature Date for Resident #1 (R1) which poses an immeidate health, safety or personal rights risk to persons in care.
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Type B
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Section Cited
CCR87608(a)(3)

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87608 Postural Supports (a) Based on the individuals preadmission appraisal....(3) A written order from a physician indicating the need for the postural support shall be maintained in the residents record. The licensing agency...
This requirement is not met as evidenced by:
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The Licensee stated to submit written order from R2, R3, R4, R8, R9 and R10 physician indicating the need for the postural support for mobility and submit proof to LPA Brown on plan of correction (POC) due date.
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Based on observation, interview and record review, the licensee did not comply with the section cited above by having Resident #2 (R2), Resident #3 (R3), Resident #4 (R4), Resident #8 (R8), Resident #9 (R9), Resident #10 (R10) with half bed rails with no written order from their physician indicating the need for the postural support for mobility which poses a potential health, safety and personal rights risks to resident in care.
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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 Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 07/15/2024 03:04 PM - It Cannot Be Edited


Created By: Melody Brown On 07/15/2024 at 02:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507

FACILITY NAME: NEW HORIZONS
FACILITY NUMBER: 331800150

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/26/2024
Section Cited
CCR
87411(g)(2)

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87411 Personnel Requirements - General (g) Prior to employment or initial presence in the facility, all employees and volunteers subject to a criminal record review shall: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) or
This requirement is not met as eveidenced by:
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Licensee submitted S8 and S9 Criminal Background Clerance Transfer Request forms (LIC9182) to LPA Brown during the visit. Plan of Correction (POC) cleared.
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Based on observation, interview, record review, the licensee did not comply with the section cited above by not transferring Staff #8 (S8) and Staff #9 (S9) criminal backgound clearance to the facility prior to employment which pose potential health, safety and personal rights risks to residents in care.
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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 Malagon
LICENSING EVALUATOR NAME:Melody Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 07/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/15/2024


LIC809 (FAS) - (06/04)
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