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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004701
Report Date: 03/26/2025
Date Signed: 04/04/2025 08:22:21 AM

Document Has Been Signed on 04/04/2025 08:22 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:NEW HORIZON BOARD & CAREFACILITY NUMBER:
347004701
ADMINISTRATOR/
DIRECTOR:		SUSANA G PEREZFACILITY TYPE:
740
ADDRESS:10172 BRENNA WAYTELEPHONE:
(916) 686-4883
CITY:ELK GROVESTATE: CAZIP CODE:
95757
CAPACITY: 6CENSUS: 2DATE:
03/26/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Susana PerezTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Vincent Moleski arrived unannounced to conduct an annual inspection. LPA Moleski met with facility administrator Suzanne Perez and explained the purpose of the visit.

LPA Moleski reviewed two resident files (R1-R2) and two staff files (S1-S2).

LPA Moleski observed R1 and R2 both had LIC 602s more than one year old. R1's LIC 602 was dated 02/06/24, and R2's was dated 01/08/2024. No documentation existed in either file that they had received, or been requested to attend, an annual routine medical visit since the date of their most recent LIC 602. Both R1 and R2 are diagnosed with dementia.

LPA Moleski toured the facility with Perez and inspected common areas, the kitchen, bedrooms, bathrooms, and backyard areas. Furniture and furnishings were sufficient to meet the needs of residents. The facility temperature was 72 degrees Fahrenheit, which is within the required range of 68 and 85 degrees. The facility's water temperature measured 108 degrees Fahrenheit, which is within the required range of 105 and 120 degrees.

[continued on 809-C]
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/26/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/04/2025 08:22 AM - It Cannot Be Edited


Created By: Vincent Moleski On 03/26/2025 at 11:39 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NEW HORIZON BOARD & CARE
FACILITY NUMBER: 347004701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, cleaning solutions, a knife, and razors were left unlocked and accessible, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Licensee removed the cleaning solutions and knives during this visit. This POC will be cleared.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, medications were not stored in a locked location, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/02/2025
Plan of Correction
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Licensee requested an extension to acquire a lock on the fridge by 4/2/25. LPA Moleski granted this extension.
Licensee agrees to provide LPA Moleski with a photograph of the
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/04/2025 08:22 AM - It Cannot Be Edited


Created By: Vincent Moleski On 03/26/2025 at 11:39 AM
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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NEW HORIZON BOARD & CARE
FACILITY NUMBER: 347004701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, two residents did not have annual routine visits, and documentation of requesting these residents to receive routine visits were not maintained, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 04/09/2025
Plan of Correction
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Licensee agrees to provide LPA Moleski with updated LIC 602s or other documentation of an annual routine visit by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: NEW HORIZON BOARD & CARE
FACILITY NUMBER: 347004701
VISIT DATE: 03/26/2025
NARRATIVE
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LPA Moleski observed first aid supplies, a fully-charged and up-to-date fire extinguisher, and working carbon monoxide/smoke detectors. LPA Moleski observed a minimum 2-day supply of perishable food and a minimum 7-day supply of nonperishable food. LPA Moleski observed a locked cabinet for the storage of medication. LPA Moleski observed locked cabinets for the storage of cleaning solutions and knives.

While touring the facility, LPA Moleski observed a disinfectant and a bleach cleaning solution in an unlocked cabinet in a resident bathroom (R1). LPA Moleski also observed an electric and standard razor in that same resident's bathroom. R1 is diagnosed with dementia. While touring the backyard, LPA Moleski observed a knife left out on top of a garbage can.

LPA Moleski observed a video monitoring system in two resident bedrooms. The devices captured both video and audio. The devices were removed during this visit.

Upon arrival, LPA Moleski observed medications in a pill dispenser, which belonged to Perez, left out on a table next to a chair in the facility living room. LPA Moleski also observed a staff member's insulin needles stored unlocked in a fridge in a common area.

LPA Moleski interviewed one staff member (S2) and one resident (R1).

This facility is hereby cited per 22 CCR Sections 87468.2(a)(1), 87309(a), 87465(h)(2), and 87463(h). An exit interview was held with Perez. Appeal rights and a copy of this report were left with Perez.
NAME OF LICENSING PROGRAM MANAGER: Stephen Richardson
NAME OF LICENSING PROGRAM ANALYST: Vincent Moleski
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
Document Has Been Signed on 04/04/2025 08:22 AM - It Cannot Be Edited


Created By: Vincent Moleski On 03/26/2025 at 12:24 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
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NEW HORIZON BOARD & CARE
FACILITY NUMBER: 347004701

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/26/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.2(a)(1)
"...residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: ... To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups."

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on obsercation, residents were not permitted a reasonable level of privacy in their private bedrooms, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Licensee agrees to provide a written acknowledgement that cameras or other audiovisual recording devices are not to be utilized in any resident rooms by POC due date.
vincent.moleski@dss.ca.gov
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Stephen Richardson
NAME OF LICENSING PROGRAM MANAGER:
Vincent Moleski
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/26/2025


LIC809 (FAS) - (06/04)
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