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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604060
Report Date: 08/19/2020
Date Signed: 08/21/2020 12:36:35 PM

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:GROSSMONT GARDENSFACILITY NUMBER:
374604060
ADMINISTRATOR:KAITLIN RUDOLPHFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: 240DATE:
08/19/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director Kaitlin RudolphTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA), Debbie Correia, contacted the facility via telephone to conduct a Case Management Visit. The visit is being conducted virtually via FaceTime due to COVID-19. LPA identified herself and explained the purpose of the call to Executive Director, Kaitlin Rudolph.

The visit was in response to a Special Incident Report CCL received on 06/26/2020 regarding an email Resident 1 (R1) sent to an outside source to report an incident between a facility Staff 1 (S1) and Resident 2 (R2). During today's visit, LPA conducted a virtual health and safety check and interview with R1 which revealed no concerns. LPA requested staff and resident records for further analysis. No deficiencies were cited during the visit.

An exit interview was conducted with Executive Director, Kaitlin Rudolph. A copy of this report (LIC811 Confidential Names) and the Licensee/Appeal Rights (LIC9058 01/16) were provided to Executive Director Kaitlin Rudolph. via email and an electronic read receipt verifies receipt of the documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) 767-2306
LICENSING EVALUATOR NAME: Debbie CorreiaTELEPHONE: (619) 407-0894
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2020
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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