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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004701
Report Date: 02/17/2023
Date Signed: 02/17/2023 04:07:07 PM


Document Has Been Signed on 02/17/2023 04:07 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, 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:
02/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Susana Perez, AdministratorTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Tung Truong arrived at this facility unannounced on 2/17/23 to conduct an annual inspection visit. LPA met with Administrator Susana 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 six (6) non-ambulatory residents and has hospice waiver for five (5) residents. There are three (3) residents in care at this time.

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 110.9 degrees Fahrenheit, which is 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 clients. Proof of current liability insurance was observed and is up to date. LPA also conducted the infection control domain tool.

Report 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: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/17/2023
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 3


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: 02/17/2023
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LPA requested resident and staff files for review. LPA reviewed two (2) resident and two (2) staff files, including criminal record clearances. LPA reviewed Fingerprint clearance and associations to the facility. LPA verified staff training for staff file reviews.

The following forms and documents were requested to be submitted within 15 days:
(1) LIC308 Designation of Administrative Responsibility
(2) LIC500 Personnel Report
(3) Copy of Administrator Certificate
(4) LIC610 Emergency Disaster Plan

No deficiencies cited from the California Code of Regulations, Title 22, and California Health and Safety Code.

Exit interview held with Administrator. A copy of the report was given at the conclusion of the visit.

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

DATE: 02/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3