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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 10/25/2022
Date Signed: 10/25/2022 11:22:54 AM


Document Has Been Signed on 10/25/2022 11:22 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:MY NEW HOME - LODI GARDENSFACILITY NUMBER:
374604584
ADMINISTRATOR:MALMBERG, PONTIUSFACILITY TYPE:
740
ADDRESS:5289 LODI STTELEPHONE:
(858) 272-5286
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY:6CENSUS: 5DATE:
10/25/2022
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Caregiver, Alma MezaTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA), Sabel Martinez, conducted an unannounced Post Licensing inspection to verify compliance with infection control practices. The LPA was greeted and granted entry to the facility by Caregiver, Alma Meza. The LPA introduced himself and disclosed the purpose of the visit with Meza.

On today's visit, the LPA observed one central entry point for universal entry screening; routine symptom screening initiated at entry for staff, residents and visitors; a sign-in policy enacted for all visitors; signs throughout the facility to promote hand hygiene, face coverings worn by staff; hand sanitizer/hand washing stations readily available; a designated visitation area; emergency agencies’ contact information posted in a location visible to staff and residents; and an adequate supply of Personal Protective Equipment (PPE).

Additionally, all of the residents’ rooms were equipped with the required furnishings. Residents’ bathrooms were observed to be sanitary and operational. The facility was stocked with a 2 day supply of perishable and a 7 day supply of nonperishable food items. Cleaning supplies and medications were observed to be locked in different locations and inaccessible to residents in care.

The licensee was granted a waiver under the Authority of the governor Newsom's Executive Order N-11-22 issued on June 17,2022, and the licensee agreed to submit the Infection Control Plan By December 23,2022.

An exit interview was conducted with Caregiver, Alma Meza. A copy of this report along with Applicant/Appeal Rights (LIC9058 01/16) were provided to the Licensee, Diep Malmberg, via electronic mail. An electronic mail read receipt confirms the documents were received by the licensee.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (610) 767-2317
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 10/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/25/2022
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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