347004701-4-2-2024-27-AS-CYAG-D3Y2SC-20240402173854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 347004701
Report Date: 03/29/2024
Date Signed: 04/02/2024 05:38:58 PM

Document Has Been Signed on 04/02/2024 05:38 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

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: 3	DATE:	03/29/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Mauricio and Susana Perez		TIME COMPLETED:	04:30 PM

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	Unannounced Annual visit made out to this facility on 03/29/2024 by Licensing Program Analyst (LPA) Charlie Yang who was met by the facility designated Administrator Mauricio Perez and Susana Perez who were briefly interviewed. It was learned that Mr. and Mrs. Perez were the Licensee(s) and facility designated Administrators at this time. They are also the live-in personnel at this facility at this time. Current census was 3 residents. There were (2) residents under the care of hospice at this time. There weren't any residents receiving the services of home health at this time. A tour of this facility was conducted. Administrator certificate was observed to be present and in compliance at this time for facility designated Administrator Susana Perez. Additional forms and documents were reviewed to make sure that the renewal process was initiated prior to the certificate expiration date of 07/14/2024 with certificate # 6018430740. Kitchen area was toured. Cabinets and drawers were reviewed. Food supply was reviewed for adequate 2-day perishable and 7-day nonperishable quantities at this time. A tour of the dining area, living area, and all other areas intended for resident use was conducted. Medication cabinet and supplies, located in the entry way closet, was reviewed. Policies and procedures involving dispensing, documenting, and overall administration of resident medications was discussed with the facility designated Administrators at this time. This medication cabinet was observed to be locked and made inaccessible to the residents at this time. A tour of the resident bedrooms and restrooms was conducted. Furniture and furnishings were observed to be sufficient and able to meet the needs of the residents at this time. Hot water temperatures were taken and measured to make sure that they were within the allowed range of 105-120 degrees. Linen closets were observed to contain a sufficient supply of towels, blankets, and linens to meet the needs of the residents at this time.

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: NEW HORIZON BOARD & CARE	FACILITY NUMBER: 347004701
	VISIT DATE: 03/29/2024

NARRATIVE

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Laundry area, located in the garage area, was toured. Cabinets storing detergents and bleach were observed to be locked and made inaccessible to the residents at this time.
Fire extinguishers (2), located in the kitchen and hallway, were observed to have been annually inspected on 07/19/2023 by the local fire extinguisher company, River City Fire, and in compliance at this time.
Exterior grounds of this facility were toured. A review of the facility perimeter fence, side gate, and exits was conducted.
A review of (3) facility resident records was conducted and noted on the following LIC 858 form.
A review of (4) facility staff records was conducted and noted on the following LIC 859 form.

The following forms and documents were requested to be updated and submitted into CCL:

LIC 308

LIC 400

LIC 500

LIC 610

There were no deficiencies observed or cited during today's annual visit.

Exit Interview

SUPERVISOR'S NAME: Liza King	TELEPHONE: (650) 676-0442
LICENSING EVALUATOR NAME: Charlie Yang	TELEPHONE: (916) 709-6507
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2024

LIC809 (FAS) - (06/04)

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