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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 361881309
Report Date: 04/21/2022
Date Signed: 04/21/2022 04:17:37 PM

Document Has Been Signed on 04/21/2022 04:17 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: 11DATE:
04/21/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Ebraheem HamedTIME COMPLETED:
11:05 AM
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Licensing Program Analysts (LPAs) Rayshaun Nickolas and Anna Bueno conducted an announced visit to the facility for the purpose of verifying corrections from the intial Pre-Licensing inspection on March 16, 2022. At approximately 10:00 AM, LPAs were greeted and granted entry by Administrator Ebraheem Hamed. LPAs observed the following:

All non-elderly residents were removed; this was confirmed by touring the facility and inspecting all residents bedrooms.
LIC 602 Admission agreement completed for residents.

Pre-licensing is now complete. Final licensure will be determined by Central Application Bureau (CAB). Licensing Program Manager (LPM) determined to waive COMP III as the Administrator/Licensee has several other facilities and has completed another Pre-Licensing visit with a COMP III on April 9, 2022. An exit interview was conducted and a copy of this report provided electronically.


SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Rayshaun Nickolas
LICENSING EVALUATOR SIGNATURE: DATE: 04/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/21/2022
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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