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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604584
Report Date: 07/22/2024
Date Signed: 07/22/2024 02:52:03 PM

Document Has Been Signed on 07/22/2024 02:52 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/
DIRECTOR:		MALMBERG, PONTIUSFACILITY TYPE:
740
ADDRESS:5289 LODI STTELEPHONE:
(858) 272-5286
CITY:SAN DIEGOSTATE: CAZIP CODE:
92117
CAPACITY: 6CENSUS: 5DATE:
07/22/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:35 AM
MET WITH:Administrator Diep MalmbergTIME VISIT/
INSPECTION COMPLETED:
03:10 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 Continuation Required Annual Inspection. The LPA introduced himself and disclosed the purpose of the visit to Administrator Pontius Malmberg. The facility was licensed for a capacity of six (6) non-ambulatory residents and approved for a hospice waiver for four (4) residents.

Administrator Diep Malmberg arrived during the visit and assisted the LPA. During today's visit the LPA reviewed additional records and conducted interviews. Technical advise was provided and deficiencies were cited in an LIC 809D page. A plan of correction was jointly formulated with Administrator Diep Malmberg.

An exit interview was conducted with Administrator Diep Malmberg, to whom a copy of this report, LIC 811, LIC 809D, and the Licensee/Appeal Rights (LIC9058), were provided.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Sabel Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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 3
Document Has Been Signed on 07/22/2024 02:52 PM - It Cannot Be Edited


Created By: Sabel Martinez On 07/22/2024 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(15)
Resident Records
(b) Each resident's record shall contain at least the following information: (15) The admission agreement and pre-admission appraisal, specified in Sections 87507, Admission Agreements and 87457, Pre-admission Appraisal.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on review of records and an interview with the administrator, the licensee did not comply with the section cited above in 1 (R5) out of 5 residents in care, which posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to submit the following records for R5, signed personal rights (LIC 627C) form, medical assessment, pre-appraisal, identification sheet, needs and services plan, and consent form, by 8/22/24.
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and review of records, the licensee did not comply with the section cited above posed a potential health, safety or personal rights risk to 5 out of 5 persons in care.
POC Due Date: 08/22/2024
Plan of Correction
1
2
3
4
Administrator agreed to review emergency drill regulation, conduct drill, document and submit proof to the LPA, by 8/22/24.
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 Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 07/22/2024 02:52 PM - It Cannot Be Edited


Created By: Sabel Martinez On 07/22/2024 at 02:02 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 07/22/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87212(b)(2)(A)
Emergency Disaster Plan
(b) The plan shall be subject to review by the Department and shall include: (2) Plan for evacuation including: (A) Fire safety plan.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and review of records, the licensee did not comply with the section cited above in, posed a potential health, safety or personal rights risk to 5 out of 5 persons in care.
POC Due Date: 08/22/2024
Plan of Correction
1
2
3
4
The administrator agreed to review emergency disaster plan regulation, implement a fire safety plan, and submit this plan to the LPA, by 8/22/24.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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 Tellez
LICENSING EVALUATOR NAME:Sabel Martinez
LICENSING EVALUATOR SIGNATURE:
DATE: 07/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/22/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3