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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601811
Report Date: 03/28/2025
Date Signed: 03/28/2025 03:07:44 PM

Document Has Been Signed on 03/28/2025 03:07 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:J & M HAPPY GUEST HOMEFACILITY NUMBER:
374601811
ADMINISTRATOR/
DIRECTOR:		MARIA DELGADOFACILITY TYPE:
740
ADDRESS:10264 AMBASSADOR AVETELEPHONE:
(858) 693-3428
CITY:SAN DIEGOSTATE: CAZIP CODE:
92126
CAPACITY: 6CENSUS: DATE:
03/28/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH: Licensee, Maria Erolyn DelgadoTIME VISIT/
INSPECTION COMPLETED:
12:16 PM
NARRATIVE
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Health Checks visit to check on the health and safety of residents in care. LPA was greeted and allowed entry into the facility and met with Licensee, Maria Erolyn Delgado.

During today's visit, LPA briefly toured the facility, observed and interviewed resident's in care, interviewed staff, review of medications, records, sufficient food supply, and physical plant.

On 03/26/25, LPA observed staff cleaning a skin tear/wound on Resident #1's hand. Staff were cleaning the wound with wound cleanser, applying anti itch lotion, and a bandage. The facility did not have the current hospice records but indicated the nurse was on their way to the facility to provide current documentation. Today, 03/28/25, a review of hospice records indicated instructions on how to clean the wound, which was not followed by the facility staff. Today, the hot water temperature for resident use measured at 135 degrees F. The licensee stated she turned the hot water temperature to hot because the water wasn't getting hot enough. The licensee posted a warning sign of the hot water temperature above the sink faucet warning users. A review of medications indicated Resident #2 and Resident #3's medications are not being given as prescribed. The facility does not use a Medication Administration Record. The facility's Centrally Stored Medication Destruction Records were not current. The licensee was unable to explain the medication errors. The bubble packs showed the prescription was issued the end of February 2025. However, the bubble pack was not punched in date order and should reflect thru today's date as medications given. The bubble packs for the end of February 2025 were only punched for up to 4 days, showing medications were not given accordingly in March 2025.

Deficiencies were observed and issued on the attached LIC 809D, along with civil penalties for repeat violations. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Licensee, Maria Erolyn Delgado whose signature below confirms receipt of these rights.
NAME OF LICENSING PROGRAM MANAGER: Robyn Clark
NAME OF LICENSING PROGRAM ANALYST: Natasha Persaud
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 03/28/2025 03:07 PM - It Cannot Be Edited


Created By: Natasha Persaud On 03/28/2025 at 11:15 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: J & M HAPPY GUEST HOME
FACILITY NUMBER: 374601811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/29/2025
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation. Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care...water. Hot water temperature...not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).
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Licensee stated she will lower the hot water temperature and provide a video showing the hot water temperature being checked by a water thermometer and within regulation by POC due date.
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This requirement is not met as evidenced by:
Based on observations the licensee did not ensure the hot water temperature was in regulation for 4 out of 4 [R1-R4] residents, which posed an immediate health and safety risk to residents in care.
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Type B
04/18/2025
Section Cited
CCR87465(a)(4)

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Incidental Medical and Dental Care. The licensee shall assist residents with self administered medications as needed. This requirement is not met as evidenced by:
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Licensee stated she couldn't explain what the medication errors. Licensee agreed to attend medication training along with all staff and submit proof of training by POC due date.
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Based on observations and interviews the licensee did not ensure medications were given as prescribed for 2 out of 4 [R2-R3] residents which posed a potential health and safety risk to residents in care.
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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.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/28/2025 03:07 PM - It Cannot Be Edited


Created By: Natasha Persaud On 03/28/2025 at 11:28 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: J & M HAPPY GUEST HOME
FACILITY NUMBER: 374601811

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/18/2025
Section Cited
CCR
87465(h)(6)

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The following requirements shall apply to medications which are centrally stored: The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by:
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Licensee stated she thought the Centrally Stored Medication Destruction Record was current. Licensee stated she will attend medication documentation training along with all staff and provide proof of training by POC due date.
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Based on record review and interviews and the licensee did not ensure a record of centrally stored prescriptions were accurately maintained for 2 out of 4 [R2-R3] residents, which posed a potential health and safety risk to residents in care.
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Type B
04/18/2025
Section Cited
CCR87633(b)

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A current and complete hospice care plan shall be maintained in the facility for each hospice resident and include the following: This requirement is not met as evidenced by:
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Licensee stated they have the wound care instructions from the hospice agency and will follow them. In addition, the licensee agreed to attend training regarding obtaining hospice orders and following them. Proof of training due by POC due date.
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Based on observations and interviews, the licensee did not have orders for skin tear/wound care on file for 1 out of 4 [R1] residents, which posed a potential health and safety risk to residents in care.
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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.
Robyn Clark
NAME OF LICENSING PROGRAM MANAGER:
Natasha Persaud
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2025


LIC809 (FAS) - (06/04)
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