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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601811
Report Date: 12/29/2023
Date Signed: 12/29/2023 05:48:58 PM


Document Has Been Signed on 12/29/2023 05:48 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, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:J & M HAPPY GUEST HOMEFACILITY NUMBER:
374601811
ADMINISTRATOR:MARIA DELGADOFACILITY TYPE:
740
ADDRESS:10264 AMBASSADOR AVETELEPHONE:
(858) 693-3428
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY:6CENSUS: 4DATE:
12/29/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Licensee, Erolyn DelgadoTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management visit. LPA was greeted and allowed entry into the facility by Staff, Norman Baloy. The Licensee, Erolyn Delgado arrived during the visit..

On 12/28/23, Community Care Licensing (CCL) received a Death Report regarding Resident #1 (R1). The report stated R1 was found unresponsive by staff on the morning of 12/28/23. The facility contacted 911 and they arrived quickly. Staff stated R1 was doing well and observed the prior night and was at regular baseline.. The cause of death was unknown

No deficiencies were observed today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Erolyn Delgado whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/29/2023
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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