342700388-10-11-2022-27-AS-TTRG-CK4NXG-20221011105106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 342700388
Report Date: 10/11/2022
Date Signed: 10/11/2022 10:51:13 AM

Document Has Been Signed on 10/11/2022 10:51 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME:	NEW HORIZON BOARD AND CARE II		FACILITY NUMBER:	342700388
ADMINISTRATOR:	PEREZ, SUSANA G		FACILITY TYPE:	740
ADDRESS:	10051 SHANA WAY		TELEPHONE:	(916) 585-9460
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 3	DATE:	10/11/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Sharon Perez		TIME COMPLETED:	11:15 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 10/11/22 at 9:00 am, Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called and spoke to facility staff who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. LPA met with Assistant Administrator Sharon Perez and explained the purpose of the visit. Administrator holds current certification #6018430740 and expires on 7/14/2024. The facility is licensed to serve up to (6) six non-ambulatory residents. Approved hospice waiver for (4) four residents. There are currently three (3) residents who reside at this facility. LPA toured the facility with Assistant Administrator Sharon Perez on 10/11/22 at 9:20 am. LPA inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition and properly maintained. The hot water temperature was observed to be 132.2 degrees Fahrenheit, which is not within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 75 degrees Fahrenheit. Food supply is adequate for 2-day perishable and 7-day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher and first aid kit was up to date. LPA checked medication storage and found medication to be locked away and inaccessible to residents. LPA completed the infection control domain tool. Continued on 809-C

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HORIZON BOARD AND CARE II	FACILITY NUMBER: 342700388
	VISIT DATE: 10/11/2022

NARRATIVE

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The facility mitigation plan was submitted to CCLD, and it was approved on 4/13/2021. Facility has routine symptom screening checks for residents, staff, and visitors. The facility has a symptom check binder for staff, residents, and care staff. Hand Hygiene procedures have been implemented. Facility had Covid-19 posters throughout the facility, and the facility has implemented Covid-19 mitigation plan.

Administrator was informed to send updated copies of the following documents to CCL within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan
(5) Proof of Current Liability Insurance

Per California Code of Regulations, Title 22, Division 6, Chapter 8, the following (1) deficiency is being cited. See 809-D for citation. Failure to correct the deficiency by the noted due date may result in a penalty being assessed.

Exit interview conducted and copy of report provided. Appeal rights given.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/11/2022 10:51 AM - 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, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

FACILITY NAME: NEW HORIZON BOARD AND CARE II	FACILITY NUMBER: 342700388
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/11/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation. Hot water provided for the use of residents shall be maintained between 105 - 120 degrees Fahrenheit. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs observation, the licensee did not maintain water temperature between 105 - 120 degrees Fahrenheit. The kitchen sink temperature was at 132.3 degrees Fahrenheit & the resident’s bathroom sink temperature was at 129.5 degrees Fahrenheit. This poses an immediate health and safety risk to residents in care.
	POC Due Date: 10/12/2022
	Plan of Correction
1 2 3 4	Facility shall maintain a hot water temperature between 105' - 120'. Facility shall monitor the hot water over the next 3 days and shall keep the temperature within acceptable regulations. Facility will provide proof of water temperature is between 105-120 by POC due date and provide LPA the water tracking log of the 3 day tracking. LPA will revisit facility to clear this deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2022

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2022

LIC809 (FAS) - (06/04)

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