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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 06/18/2024
Date Signed: 06/18/2024 04:10:44 PM


Document Has Been Signed on 06/18/2024 04:10 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
SAN DIEGO RO, 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:
06/18/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Administrator Diep Malmberg and Caregiver Alma MezaTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Case Management Visit to observe the facility's physical plant. The LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Caregiver Alma Meza.

Administrator Diep Malmberg arrived during the visit and assisted the LPA.

During the visit, the LPA toured the facility and inspected the facility's bathrooms. It was previously reported to the Department the facility was in the process of remodeling the facility bathrooms.

No deficiencies were cited on today's date, but additional visits may be necessary.

An exit interview was conducted with Administrator Malmberg, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058), were provided via email. An email read receipt confirms the documents were received by Malmberg.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/18/2024
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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