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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004701
Report Date: 07/01/2021
Date Signed: 07/01/2021 02:39:06 PM

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 & CAREFACILITY NUMBER:
347004701
ADMINISTRATOR:SUSANA G PEREZFACILITY TYPE:
740
ADDRESS:10172 BRENNA WAYTELEPHONE:
(916) 686-4883
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY:6CENSUS: 3DATE:
07/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Susan Perez, AdministratorTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 07/1/2021 at 1:20 PM to conduct an annual inspection visit. LPA met with administrators Susana Perez and Mauricio Perez, Jr. and explained the purpose of the visit.

Administrator Susana Perez holds current certification #6018430740 and expires on 7/14/2022. The facility is licensed to serve up to six (6) non-ambulatory residents and has hospice waiver for five (5). There are currently three (3) residents of which two (2) are on hospice. LPA toured the facility with administrator Mauricio Perez, Jr. on 07/1/2021 at 1:30 PM.

LPA inspected the physical plant including but not limited to the common areas, kitchen, dining area, resident bedrooms; resident bathrooms, laundry room, activity room, and outside courtyards of the facility to ensure compliance with Title 22 regulations. The facility was in compliance. LPA observed bedrooms to be properly furnished, with appropriate bedding and lighting. The bathrooms were in sanitary condition, properly maintained and the hot water temperature was observed to be 106.9 degrees Fahrenheit. LPA observed there to be a sufficient amount of perishable and non-perishable food supply on hand. LPA observed knives and toxins to be locked away and inaccessible to clients. LPA checked medication storage and found medication 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 also conducted the infection control domain tool.

Continued on 809-C
SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
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 & CARE
FACILITY NUMBER: 347004701
VISIT DATE: 07/01/2021
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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.

The following documents were requested:

-Personnel Report (LIC 500)
-Emergency Disaster Plan
-Qualification of Administrator
-Designation of Administrative Responsibility. (LIC 308)
-Control of Property

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit.

Exit interview was held and a report was given.

SUPERVISOR'S NAME: Czarrina A Camilon-LeeTELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung TruongTELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:

DATE: 07/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2021
LIC809 (FAS) - (06/04)
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