<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374601811
Report Date: 09/28/2023
Date Signed: 09/28/2023 11:43:25 AM

Document Has Been Signed on 09/28/2023 11:43 AM - 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:
09/28/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Caregiver Norman Baloy and Licensee Maria DelgadoTIME COMPLETED:
11:50 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Norman Baloy. LPA also met with Licensee Maria Delgado, who arrived later during the visit.

On 08/31/2022, the CCLD San Diego Regional Office met with the licensee for a Non-Compliance Conference (NCC).

During today’s visit, LPA conducted a general tour of the facility and performed a welfare check on residents in care. LPA also interviewed residents and staff, reviewed personnel and training records, and evaluated licensee’s ongoing compliance with the actions/objectives that they agreed to during the NCC.

No deficiencies were observed or issued during today's visit.

An exit interview was conducted with Delgado, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Dang Nguyen
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1