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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 03/07/2023
Date Signed: 03/07/2023 05:33:03 PM


Document Has Been Signed on 03/07/2023 05:33 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: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:
03/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
05:19 PM
MET WITH:Caregiver Alma MecaTIME COMPLETED:
05:39 PM
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 to observe the facility's physical plant. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alma Meca.

On 10-21-2022, the licensee submitted an LIC200 Application to the CCLD San Diego Regional Office (RO) to amend the facility's floor plan, by adding one (1) resident room.

On 11-04-2022, the local fire authority granted an updated fire clearance, showing the facility’s bedroom addition was approved. There were no changes to the facility’s licensed capacity or non-ambulatory status.

During today’s visit, LPA conducted a brief tour of the facility to view the bedroom addition, which had working lighting and contained the required furnishings for future resident use. Licensee's updated facility sketch/floor plan was also consistent with the current layout of the facility. LPA observed no immediate health or safety issues. No deficiencies were cited.

This portion of the application process is complete. Pending CCLD management’s final review and approval, the licensee will be sent an updated license to reflect the new fire clearance.

An exit interview was conducted with Meca, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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