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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 455002744
Report Date: 08/27/2024
Date Signed: 09/10/2024 11:42:16 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240702161201
FACILITY NAME:HORIZON ET AL, LLCFACILITY NUMBER:
455002744
ADMINISTRATOR:LAWSON, STEPHENFACILITY TYPE:
740
ADDRESS:1023 GREENBRIAR CTTELEPHONE:
(530) 227-5020
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 3DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Licensee, Colleen Lawson
Administrator, Stephen Lawson		TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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medications not recorded as required
medications not disposed of as required
medication dispensed records have forged initials
Residents confined to bed
insufficient night time supervision for wandering residents
staff training not complete
Facility not maintained clean
Medications not stored securely
Staff Member was acting inappropriately
Lack of Supervision of resident
INVESTIGATION FINDINGS:
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"AMENDED" This is an amended version of the original report created on August 27, 2024-SEE BELOW.

On September 10, 2024 at approximately 10:00 AM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of delivering amended complaint findings for a complaint that was generated on July 2, 2024. Upon arrival, LPAs were greeted at the door by Administrator, Stephen Lawson, and was granted access into the facility. Licensee arrived 30 minutes later.

During the course of the investigation, LPA reviewed facility records, resident records, interviewed staff, residents in care and toured the facility on July 9, 2024, July 16, 2024, July 29, 2024 and August 20, 2024.

Complaint alleges that medications are not recorded as required. During the course of the investigation, LPA interviewed staff members and received inconsistent statements as it relates to the allegation. Furthermore, LPA reviewed the Medication Administration Record (MAR) and could not find any concerns as it relates to medications not being recorded. (Report continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 59-AS-20240702161201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HORIZON ET AL, LLC
FACILITY NUMBER: 455002744
VISIT DATE: 08/27/2024
NARRATIVE
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"AMENDED" This is an amended version of the original report created on August 27, 2024-SEE BELOW.

Complaint alleges that Medications are not disposed of as required and Medications are not stored securely. During the course of the investigation, LPA toured the facility on July 9, 2024, and observed no evidence to suggest that medications are left unsecured or on the floor. On July 16, 2024, LPA conducted a subsequent complaint investigation inspection and toured the facility which included the garage. LPA observed no evidence of medications being on the floor or unsecured. LPA observed the medication room where medications are locked and stored inaccessible to residents in care and found no concerns. On July 29, 2024, LPAs, Farhaan Sarangi and Sarah Benson conducted a subsequent complaint investigation inspection, LPAs toured the facility and observed no evidence of medications being on the floor or unsecured in the garage and the medication room. On August 20, 2024, LPA conducted a subsequent complaint investigation inspection and toured the facility which included the garage. LPA observed no evidence of medications being on the floor or unsecured.

Complaint alleges that medication dispensed records have forged initials. During the course of the investigation, LPA interviewed the staff members and reviewed the Medications Administration Record (MAR). LPA observed no forge initials on the suspected dates of administration. Furthermore, LPA received inconsistent statements and could not corroborate the allegation.

Complaint alleges Residents are confined to bed. Based on LPA observations during the tour of the facility on July 9, 2024, July 16, 2024, July 29, 2024 and August 20, 2024. LPA could not corroborate the allegation that residents are confined to bed. Furthermore, during said tours, LPA observed no chairs or any other items blocking the access of resident rooms or beds.

Complaint alleges insufficient nighttime supervision for wandering residents. During the course of the investigation, LPA received inconsistent statements and could not corroborate the allegation. Attempted interviews were conducted with the residents on July 9, 2024, which were unsuccessful due to the residents sharing limited information to the LPA.

(Report continued on LIC 9099C)
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 59-AS-20240702161201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HORIZON ET AL, LLC
FACILITY NUMBER: 455002744
VISIT DATE: 08/27/2024
NARRATIVE
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"AMENDED" This is an amended version of the original report created on August 27, 2024-SEE BELOW.

Complaint alleges that staff training not complete. During the course of the investigation, LPA reviewed staff records and observed no concerns as it relates to staff training. LPA learned that staff members who provide care and supervision have valid First Aid/CPR Cards. Furthermore, LPA could not corroborate the allegation due to inconsistent statements.

Complaint alleges that Facility not maintained clean. Based on observation and tours of the facility on July 9, 2024, July 16, 2024, July 29, 2024 and August 20, 2024, LPA observed the facility to be clean with all exits free from obstruction. LPA could not corroborate the allegation.

Complaint alleges Staff Member was acting inappropriately and Lack of Supervision of resident. During the course of the investigation, LPA interviewed staff members and learned of no concerns as it relates to the alleged staff member acting inappropriately. Furthermore, LPA made an attempt to interview residents in care on July 9, 2024 but was unsuccessful due to the residents sharing limited information. LPA observed residents to be content in placement.

A finding that the complaint allegation of medications not recorded as required, medications not disposed of as required, medication dispensed records have forged initials, Residents confined to bed, insufficient night time supervision for wandering residents, staff training not complete, Facility not maintained clean, Medications not stored securely, Staff Member was acting inappropriately and Lack of Supervision of resident are unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED. Exit interview was conducted and a copy of this was report was signed, printed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/02/2024 and conducted by Evaluator Farhaan Sarangi
COMPLAINT CONTROL NUMBER: 59-AS-20240702161201

FACILITY NAME:HORIZON ET AL, LLCFACILITY NUMBER:
455002744
ADMINISTRATOR:LAWSON, STEPHENFACILITY TYPE:
740
ADDRESS:1023 GREENBRIAR CTTELEPHONE:
(530) 227-5020
CITY:REDDINGSTATE: CAZIP CODE:
96003
CAPACITY:6CENSUS: 3DATE:
08/27/2024
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Caregiver, Shannon Howard
Administrator, Stephen Lawson		TIME COMPLETED:
01:30 PM
ALLEGATION(S):
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medications not dispensed as prescribed
Child monitors used for supervision
staff not criminal record cleared
INVESTIGATION FINDINGS:
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On August 27, 2024 at approximately 12:30 PM, Licensing Program Analyst (LPA), Farhaan Sarangi arrived unannounced for the purpose of delivering complaint findings. Upon arrival, LPAs were greeted at the door by Caregiver, Shannon Howard, and was granted access into the facility. Administrator, Stephen Lawson arrived 20 minutes later.

During the course of the investigation, LPA reviewed facility records, resident records, interviewed staff, residents in care and toured the facility on July 9, 2024, July 16, 2024, July 29, 2024 and August 20, 2024.

Complaint alleges that medications are not dispensed as prescribed. During the course of the investigation, LPA reviewed the Medication Administration Record (MAR) and observed that a resident was prescribed a medication order for 4:00 PM daily. However, during the MAR review, LPA observed that the medication was being administered at 08:00 PM instead of what the medication order indicated. (Report continued on LIC 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 59-AS-20240702161201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME: HORIZON ET AL, LLC
FACILITY NUMBER: 455002744
VISIT DATE: 08/27/2024
NARRATIVE
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LPA conducted an interview with the Licensee on July 9, 2024, at 10:38 AM and learned that the Licensee was under the assumption that it would be beneficial to give the medication at 08:00 PM instead of what the medication order indicated. LPA educated the Licensee on the importance of dispensing medications at the appropriate times and per doctors orders (See LIC 9099D).

Complaint alleges that Child monitors used for supervision. Based on observation, LPA toured the facility on July 9, 2024, and July 16, 2024, and observed no monitoring. However, during a tour of the facility on July 29, 2024, both LPA Farhaan Sarangi and Sarah Benson observed a audio/child monitoring device in Resident #1’s room. The Caregiver on duty that day removed the audio/child monitor and placed it on top of the kitchen microwave. LPA educated the Licensee regarding the importance of ensuring that staff members including administrative staff are providing the Care and Supervision as outlined in Title 22 regulation and not depending on audio/child monitoring systems in bedrooms of residents in care (See LIC 9099D).

Complaint alleges that staff are not criminal record cleared. Based on observation of facility records which included the Guardian on July 10, 2024, LPA observed that Caregiver #1 has not been background cleared and is currently “In Process.” A subsequent complaint investigation inspection was conducted on July 16, 2024, and Caregiver #1 was observed providing Care and Supervision to residents in care. LPA educated the Licensee regarding ensuring that ALL staff are background cleared PRIOR to working at a Residential Care for the Elderly (RCFE) facility (See LIC 9099D and LIC 421BG-Civil Penalty).

Deficiencies cited from the California Code of Regulations, Title 22, Division 6, Chapter 8 of California Regulation. Civil Penalty assessed in the amount of $100.00 due to Uncleared Staff Member. Appeal rights were provided. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in additional civil penalties. Exit interview was conducted, and a copy of this report was signed and given to the Administrator.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 59-AS-20240702161201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HORIZON ET AL, LLC
FACILITY NUMBER: 455002744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
87465(c)(2)
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87465(c)(2) Incidental Medical and Dental Care

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

(2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement was not met as evidenced by:
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Licensee to submit an LIC 9098 understanding of the regulation. Furthermore, Licensee shall conduct staff training and provide a statement on how future compliance will be met.
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Based on LPA observation on July 9, 2024, LPA observed that a resident was prescribed a medication order for 4:00 PM daily. However, during the Medication Administration Review review, LPA observed that the medication was being administered at 08:00 PM instead of what the medication order indicated which presents an immediate health, safety and personal rights risk to the residents in care.
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POC due by: September XX, 2024
Type A
08/28/2024
Section Cited
CCR
87468.2(a)(1)
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87468.2(a)(1) Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:

(1) To have a reasonable level of personal privacy in accommodations, medical treatment, personal care and assistance, visits, communications, telephone conversations, use of the Internet, and meetings of resident and family groups.

This requirement was not met as evidenced by:
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Licensee to submit an LIC 9098 understanding of the regulation. Furthermore, Licensee shall conduct staff training and provide a statement on how future compliance will be met.

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During a tour of the facility on July 29, 2024, Licensing Program Analysts (LPAs) Farhaan Sarangi and Sarah Benson observed an audio/child monitoring device in Resident #1’s room which presents an immediate health, safety and personal rights risk to the residents in care.
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POC due by: September 02, 2024
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 59-AS-20240702161201
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: HORIZON ET AL, LLC
FACILITY NUMBER: 455002744
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2024
Section Cited
CCR
87355(a)
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87355(a) Criminal Record Clearance
(a) The Department shall conduct a criminal record review of all individuals specified in Health and Safety Code section 1569.17 and shall have the authority to approve or deny a facility license, or employment, residence, or presence in the facility, based upon the results of such review.

This requirement was not met as evidenced by:
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Licensee shall submit an LIC 9098 understanding of the regulation and a plan for future compliance. In addition, Licensee shall ensure that ALL staff members are associated to the facility with an “Eligible/Cleared” designation on the Guardian system before providing Care and Supervision to residents in a Residential Care for the Elderly (RCFE).
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Based on observation of facility records which included the Guardian on July 10, 2024, LPA observed that Caregiver #1 has not been background cleared and is currently “In Process” which presents an immediate health, safety and personal rights risk to the residents in care.
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POC due: September 02, 2024.
Type A
08/28/2024
Section Cited
CCR
87761(b)
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87761(b)

(b) Notwithstanding Section 87761(a) above, an immediate penalty of $100 per cited violation per day for a maximum of five (5) days shall be assessed if any individual required to be fingerprinted under Health and Safety Code Section 1569.17(b) has not obtained a California clearance or a criminal record exemption, requested a transfer of a criminal record clearance or requested and be approved for a transfer of an exemption as specified in Section 87355(e) prior to working, residing or volunteering in the facility.
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Civil Penalty assessed in the amount of $100.00
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lauren Crocker
LICENSING EVALUATOR NAME: Farhaan Sarangi
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7