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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601811
Report Date: 09/29/2022
Date Signed: 09/29/2022 10:51:14 PM

Document Has Been Signed on 09/29/2022 10:51 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: 3DATE:
09/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Licensee, Maria Erolyn DelgadoTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced annual required licensing inspection. LPA was greeted and allowed entry into the facility by Licensee, Maria Erolyn Delgado. LPA met with Licensee, Maria Erolyn Delgado and stated purpose of today’s visit, to verify compliance with statutes, regulations and other written requirements that are most relevant to protecting the health of residents in care and staff, including in the area of infection control practices.

LPA conducted a tour of the facility and observed residents in care. In accordance with the Department’s Infection Control, LPA provided consultation, observed, and evaluated the facility's implementation of their COVID-19 Mitigation Plan, to include disinfection, testing, vaccination, screening protocols, and the use of personal protective equipment.

During the tour, LPA observed Technical Assistance was needed and provided assistance in the areas observed. LPA observed the facility does not have Covid-19 signs posted. Licensee was made aware to post signs. Licensee has not notified residents about facility infection control policies. Licensee and staff have not been N95 fit tested. Licensee has not provided ongoing updates about infection control to residents and staff. Facility has not notified residents that CDSS PINs and CDSS PIN summaries for residents are available in an easily accessible location. Licensee does not have a 30 day supply of PPE or a list including items on hand or indicating where such items will be acquired and when. PPE is not stored in a location that is readily accessible to staff. Licensee is storing some PPE under her bed. Licensee does not have a contingency plan to address PPE supply shortages, including extended use and reuse in accordance with CDC guidelines.

Advisory Notes regarding Technical Assistance were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Licensee, Maria Erolyn Delgado whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/29/2022
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 HOME
FACILITY NUMBER: 374601811
VISIT DATE: 09/29/2022
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 Licensee does not have a 30 day supply of PPE or a list including items on hand or indicating where such items will be acquired and when. PPE is not stored in a location that is readily accessible to staff. Licensee is storing some PPE under her bed. Licensee does not have a contingency plan to address PPE supply shortages, including extended use and reuse in accordance with CDC guidelines.

Advisory Notes regarding Technical Assistance were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Licensee, Maria Erolyn Delgado whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022
LIC809 (FAS) - (06/04)
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