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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881309
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:22:20 PM

Document Has Been Signed on 03/16/2022 01:22 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, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME:GOLDEN HORIZON SENIOR CAREFACILITY NUMBER:
361881309
ADMINISTRATOR:HAMED, EBRAHEEMFACILITY TYPE:
740
ADDRESS:1524 S EUCLID AVETELEPHONE:
(786) 564-3771
CITY:ONTARIOSTATE: CAZIP CODE:
91762
CAPACITY: 22CENSUS: 21DATE:
03/16/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Administrator Ebraheem HamedTIME COMPLETED:
01:26 PM
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Licensing Program Analysts (LPAs) Anna Bueno and Reyshaun Nickolas made an announced visit to the facility for the purpose of conducting a pre-licensing inspection visit. LPAs met with Administrator Ebraheem Hamed. LPAs and Administrator toured the facility inside and out.

The pending initial application is for a Residential Care Facility for the Elderly (RCFE). Fire Clearance inspection was completed on 3/8/2022 and the property has been granted a fire clearance for a maximum capacity of 22 ambulatory residents only. Facility is a single story home with 11 bedrooms, 5 bathrooms, living room, dining room, and kitchen. There are no bodies of water. Appropriate patio furniture was present.

LPAs observed proper required accommodations in resident bathrooms. Smoke detectors were operable. Carbon monoxide device was operable. Fire extinguisher are charged and last inspected on 8/23/2021. Hot water is kept between 105-120 degrees F. LPAs observed required postings including Resident's Personal Rights, the Department's complaint poster, the Ombudsman's poster, and the facility's emergency/disaster plan.

The kitchen area was observed for the ability to serve food and maintained cleanliness. Temperatures for refrigerator and freezer were at ideal ranges. Dishes, utensils, glasses are present and in working order. Dishwasher will be used to clean and sanitize dishes. LPAs observed 2 days of perishable food items and 7 days of non perishable goods.

Bedrooms have the required furnishings and sufficient storage space and lighting. Facility has an adequate supply of linens and towel. Medication and resident and staff files will be stored in a locked cabinet and a locked box for medications needing refrigeration will be
CONTINUED ON LIC812-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE: DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/16/2022
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 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
, CA 92507
FACILITY NAME: GOLDEN HORIZON SENIOR CARE
FACILITY NUMBER: 361881309
VISIT DATE: 03/16/2022
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purchased and stored in the refrigerator. Three complete first aid kits was observed in the kitchen, office, and outdoors. The administrator's office will be used as a secured general storage area for dangerous objects, cleaning supplies, and toxins and will be kept inaccessible to residents.

LPAs did not observe any potential hazards within the facility at the time of visit. The property appears to be in good repair and safe for resident use.

The facility currently has 21 clients in care, 8 of which are elderly. The following corrections need to be performed before the pre-licensing inspection is completed:
  • LIC 602A and Admissions agreement need to be completed for the remaining residents.
  • Removal of non elderly residents, in excess of the allowable population.

An exit interview was conducted where this report was discussed and a copy was provided to Administrator Hamed.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Anna Bueno
LICENSING EVALUATOR SIGNATURE:

DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/16/2022
LIC809 (FAS) - (06/04)
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