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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331881125
Report Date: 07/14/2022
Date Signed: 07/14/2022 04:17:52 PM

Document Has Been Signed on 07/14/2022 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
RIVERSIDE, CA 92507
FACILITY NAME:GOLDEN HORIZON HOME 1FACILITY NUMBER:
331881125
ADMINISTRATOR:GRACE-MARIE TOMAS NGUYENFACILITY TYPE:
740
ADDRESS:15710 SILVER SPUR ROADTELEPHONE:
(702) 686-2418
CITY:RIVERSIDESTATE: CAZIP CODE:
92504
CAPACITY: 6CENSUS: 5DATE:
07/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:34 PM
MET WITH:Staff- Josefina Degutierez TIME COMPLETED:
04:25 PM
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Licensing Analyst Program (LPA) Janira Arreola, made an unannounced visit to the facility for the purpose of an annual with emphasis on infection control. LPA was greeted and granted enter by Josefina Deguttierez, who was informed of the purpose of the visit. At the time of the visit there were (3) staff and (5) residents present.

LPA toured the interior and exterior of the facility. LPA observed appropriate postings in facility entrance and common areas. LPA observed a single entry point where symptoms screenings and temperature checks occur daily for all visitors. LPA reviewed binder where facility is keeping track of visitor vaccination cards. LPA observed a sufficient 30 day supply of PPE equipment in the facility supply closet, as well as enough hand soap, toilet paper, and paper towels in all (2) resident restrooms.
LPA spoke with Administrator, Grace-Marie Tomas over the phone during the visit. Administrator informed LPA that staff are receiving COVID-19 leave that is non-punitive, and that staff have been training by a professional in proper PPE usage. Administrator shared contingency plan for staffing shortages and PPE shortages as well. LPA was informed by administrator that resident rooms would be used for isolation purposes. LPA was informed of the plan to ensure high touch surfaces, isolation rooms, and common areas are cleaned. The facility has a plan in place to monitor the residents in the isolation rooms, and for any changes in condition.

LPA will issue technical advisory note LIC9102TA for staff to start documenting staff and resident temperatures. In addition LIC9102TA will be documented for staff to be N95 FIT tested.

No deficiencies were issued at the time of the visit. An exit interview was conducted where this report was reviewed and provided to facility staff, Josefina Deguttierez.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Janira Arreola
LICENSING EVALUATOR SIGNATURE: DATE: 07/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2022
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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