347004701-3-1-2022-27-AS-TTRG-CC4PPJ-20220301102934

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004701
Report Date: 03/01/2022
Date Signed: 03/01/2022 10:29:44 AM

Document Has Been Signed on 03/01/2022 10:29 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 & CARE		FACILITY NUMBER:	347004701
ADMINISTRATOR:	SUSANA G PEREZ		FACILITY TYPE:	740
ADDRESS:	10172 BRENNA WAY		TELEPHONE:	(916) 686-4883
CITY:	ELK GROVE	STATE: CA	ZIP CODE:	95757
CAPACITY:	6	CENSUS: 4	DATE:	03/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Susana Perez, Administrator		TIME COMPLETED:	10:40 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	Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 03/01/2022 at 8:40 AM to conduct an annual inspection visit. Prior to entering the facility, LPA Truong called the facility and spoke to staff, who confirmed no residents or staff have had any symptoms of COVID-19 in the last 10 days. LPA met with Administrator Susana Perez and explained the purpose of the visit. Administrator 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 four (4) residents of which two (2) are on hospice. LPA toured the facility with Administrator Susana Perez on 03/01/2022 at 8:50 AM. LPA inspected the physical plant including but not limited to the common area, kitchen, pantry, dining area, resident bedrooms, resident bathrooms, laundry room, 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 115 degrees Fahrenheit, which is within the required regulation of 105 to 120 degrees Fahrenheit. Facility thermostat observed at 76 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 residents. 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 also conducted 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: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

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 & CARE	FACILITY NUMBER: 347004701
	VISIT DATE: 03/01/2022

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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) LIC610 Emergency Disaster Plan
(4) Proof of Current Liability Insurance
(5) Control of Property
(6) Copy of Administrator Certificate

Per California Code of Regulations, Title 22, no deficiencies were observed during this visit. Exit interview was conducted and a copy of this report was provided.

SUPERVISOR'S NAME: Czarrina A Camilon-Lee	TELEPHONE: (916) 263-4723
LICENSING EVALUATOR NAME: Tung Truong	TELEPHONE: (916) 201-7895
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2022

LIC809 (FAS) - (06/04)

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