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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:33:57 PM


Document Has Been Signed on 07/10/2024 04:33 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
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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Administrator Diep MalmbergTIME COMPLETED:
03:55 PM
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Licensing Program Analyst (LPA) Sabel Martinez conducted an unannounced Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Diep Malmberg. The facility was licensed for a capacity of six (6) non-ambulatory residents and approved for a hospice waiver for four (4) residents.

The LPA, accompanied by the administrator, toured the interior and exterior of the facility, and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstructions and slip hazards. Resident bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order.

The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. There was at least 2 days of perishable food, and at least 7 days non-perishable food present, all safely stored. Cooking and dining equipment and utensils were present. There were no toxic chemicals/poisons accessible to residents. Medications were labeled, and stored in a locked area..

No pools or bodies of water on the premises. Per staff, no firearms or ammunition are kept at the facility. A Carbon monoxide detectors, emergency lighting, and Fire extinguisher were present.

The LPA reviewed resident records. No immediate health, nor safety concerns were observed, nor cited on today's date. Due to time constraints, a return visit on a subsequent day is needed to complete the annual inspection.

An exit interview was conducted with Administrator Diep Malmberg, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058) were provided via electronic mail. An electronic mail 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: 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)
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