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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 07/10/2024
Date Signed: 07/10/2024 01:40:42 PM


Document Has Been Signed on 07/10/2024 01:40 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: 5DATE:
07/10/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Administrator Diep MalmbergTIME COMPLETED:
01:50 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) Sabel Martinez conducted an unannounced follow up Case Management Visit to observe the facility's physical plant. The LPA introduced himself and disclosed the purpose of the visit to Administrator Diep Malmberg..

The visit was in response to an email received by the Department from the facility administrator. This email notified the Department of remodeling of bathrooms and a modification in shower schedule.

After a tour of the facility, review of records, and an interview of the administrator, it was determined the administrator did not secure building permits. This deficiency was cited in accordance with California Code of Regulations, Title 22, in an LIC 809D form. A plan of correction was jointly formulated with Diep Malmberg.

An exit interview was conducted with Administrator Dep Malmberg, to whom a copy of this report, LIC 809D, and Licensee/ Appeal Rights (LIC 9058), were provided.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
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 2


Document Has Been Signed on 07/10/2024 01:40 PM - 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
SAN DIEGO RO, 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: 07/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2024
Section Cited
CCR
87305(a)

1
2
3
4
5
6
7
87305 Alterations to Existing Building or New Facilities(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement was not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to reach out to the city for a building permit and submit a new facility sketch to the LPA, 8/10/24.
8
9
10
11
12
13
14
Based on observation, review of records, and an interview of the administrator, the licensee did not obtain a building permit prior to construction and alterations made to the facility, which posed a potential personal rights, health, and safety risk to 5 of 5 residnets in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Lizzette TellezTELEPHONE: (619) -76-2351
LICENSING EVALUATOR NAME: Sabel MartinezTELEPHONE: (619) 767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 07/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2