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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881125
Report Date: 05/20/2021
Date Signed: 06/03/2021 08:14:35 AM

Document Has Been Signed on 06/03/2021 08:14 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:GOLDEN HORIZON HOME 1FACILITY NUMBER:
331881125
ADMINISTRATOR:NGUYEN, GRACE-MARIEFACILITY TYPE:
740
ADDRESS:15710 SILVER SPUR ROADTELEPHONE:
(702) 686-2418
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 5DATE:
05/20/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:TIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA), Stephanie Torres, conducted an announced pre-licensing inspection to the facility. The LPA met with Licensee/Administrator, Grace Nguyen.

Application: The application is for a Residential Care Facility for the Elderly (RCFE). The fire clearance has been granted for six (6) non-ambulatory residents, of which one (1) may be bedridden.

Buildings and Grounds: The home is composed of six (6) resident bedrooms, one (1) staff bedroom, three (3) bathrooms, a utility room (with laundry), a living room, kitchen and formal/informal dinning areas, a front/back yard areas (with seating), and a garage. The interior/exterior walkways of the home were observed to be clutter free with no obstructions present. Smoke and Carbon Monoxide detectors were tested and operable. There are no pools or other bodies of water located at the home. According to Nguyen, there are no weapons stored in the home. Rooms, furniture, beds, mattresses are all in good repair. The bedrooms are completely furnished and privacy is available. The dining and living room areas are clutter free and in good condition. Bathrooms were observed to have non-slip mats available. The tank-less water heater measured at 116.6 degrees Fahrenheit, which is within regulatory limits. Outdoor areas had sufficient room for activities and leisure. A washing machine and dryer are available and in working order.

Storage and Supplies: Activities were observed to be available and in sufficient amount for the requested census. Medications will be stored inaccessible to any unauthorized individuals. Secured areas are available for facility files and resident files. The first aid kit was observed to be available and complete. Cleaning supplies will be stored away in a secured closet, which is located near the formal dinning room. Linens, and equipment are all in good repair and sufficient for approved census. A Fire extinguisher was available and fully charged.

Food Service: Utensils and dishware are sufficient for the requested capacity. The refrigerator and stove
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2021
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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: GOLDEN HORIZON HOME 1
FACILITY NUMBER: 331881125
VISIT DATE: 05/20/2021
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are in working order. Sharps will be stored in a locked kitchen drawer, available only to authorized individuals.

Forms: The following signs were observed to be available at the home: Emergency Disaster Plan (LIC 610E), Theft and Loss Policies, Visitors Policy, Personal Rights, and Facility Sketch (LIC 999), Labor Law Information, and Complaint Information.

Corrections: Paint chipping in bedroom five (5).

The LPA will inform the Centralized Applications Bureau (CAB) the home is ready for licensure upon confirmation of corrections. This report was discussed with and a copy provided to Nguyen.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Stephanie Torres
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2021
LIC809 (FAS) - (06/04)
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