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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 01/26/2023
Date Signed: 01/26/2023 11:23:43 AM


Document Has Been Signed on 01/26/2023 11:23 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: 6DATE:
01/26/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:31 AM
MET WITH:Diep MalmbergTIME COMPLETED:
11:29 AM
NARRATIVE
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Licensing Program Analyst (LPA) Ramon Serrano conducted an unannounced case management visit to cite a deficiency noted during the initial complaint investigation visit. LPA met with Licensee Diep Malmberg and we discussed purpose of the visit.

The following deficiency was noted: admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and the licensee or the licensee’s designated representative no later than seven days following admission.

Records review revealed a facility effective date of July 5, 2022. On December 19, 2022 Licensee Diep Malmberg advised LPA Serrano that a new admission agreement had not been presented to the existing residents of the previous facility.

Interview with licensee on January 19, 2023 revealed they have not sent out new admission agreements to the existing residents of the previous facility. Licensee explained that five residents are currently covid positive and they cannot send the new admission agreement out while the residents are sick.

Per Title 22, Division 6, Chapter 8 of the California Code of Regulations, the following deficiency is cited and listed on LIC809-D.

An exit interview was conducted with Diep Malmberg to whom a copy of this report and the Appeal Rights (LIC9058 3/22) were provided to licensee.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
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 01/26/2023 11:23 AM - It Cannot Be Edited

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: MY NEW HOME - LODI GARDENS
FACILITY NUMBER: 374604584

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/26/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/30/2023
Section Cited

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Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident or the resident’s representative, if any, and...representative no later than seven days following admission. This requirement has not been met as evidenced by:
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Licensee Diep Malmberg stated she will generate and send the new admission agreement to four residents on 1/30/23 and will also send to LPA Serrano on 1/30/23.
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Based on LPA interview the licensee did not provide an admission agreement for 4 in 4 of [6] persons in care which posed a potential Personal Rights risk to persons 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.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Ramon SerranoTELEPHONE: (619) 458-2583
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2023
LIC809 (FAS) - (06/04)
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