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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601811
Report Date: 11/30/2023
Date Signed: 11/30/2023 06:58:09 PM

Document Has Been Signed on 11/30/2023 06:58 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: 5DATE:
11/30/2023
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
03:25 PM
MET WITH:Staff, Norman BaloyTIME COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an Plan of Correction visit. LPA was greeted and allowed entry into the facility and met with Staff, Norman Baloy.

On 10/25/23, an annual inspection was conducted and deficiencies were issued. The following deficiencies were issued: Maintenance and Operation- hot water measured at 150 degrees F.; Incidental Medical and Dental Care- medications stored in the fridge were not locked and the licensee was crushing and camouflaging resident's medications; Reappraisals- current appraisals were not completed; and Liability insurance- Liability insurance was expired.

On 10/25/23, during the visit, the licensee posted warning signs over the sink indicating the water was too hot, which corrected the deficiency but the licensee was also supposed to ensure the temperature was in compliance. On 10/26/23, the licensee submitted proof of a lock box for medications, correcting the deficiency.

Today, LPA observed the hot water temperature measured at 141 degrees F., which is a repeat violation as the water is still not in compliance. Staff placed another warning sign over the sink. The medications were in a locked box located in the fridge. The licensee attended in-service medication training and provided proof of training. All residents now have current appraisals on file. The licensee obtained liability insurance and provided proof of insurance. All corrections have been made except for the hot water temperature.

Based on observations, a deficiency is being issued along with a civil penalty for a repeat violation within a 12 month period. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Staff, Norman Baloy whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
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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Document Has Been Signed on 11/30/2023 06:58 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/30/2023 at 03:55 PM
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: 11/30/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/01/2023
Section Cited
CCR
87303(e)(2)

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Maintenance and Operation. Water supplies...shall be maintained as follows: (2) Faucets used by residents for personal care...shall deliver hot water. Hot water temperature...not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
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Staff placed a warning sign above the sink. Licensee stated she thought the water was fixed but does not have a water thermometer to measure. Licensee stated she will have staff fix it and if that does not work she will hire a professional and ensure the temperature is in compliance.
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Based on observations, the licensee did not ensure the hot water temperature was in compliance for 5 out of 5 residents [R1-R5] when it measured at 141 degrees F. which posed an immediate safety risk to residents in care.
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A civil penalty is being assessed for a repeat violation within a 12 month period.

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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.
SUPERVISOR'S NAME:Lizzette Tellez
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


LIC809 (FAS) - (06/04)
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