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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604060
Report Date: 11/08/2022
Date Signed: 11/08/2022 04:34:47 PM


Document Has Been Signed on 11/08/2022 04:34 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GROSSMONT GARDENS SENIOR LIVINGFACILITY NUMBER:
374604060
ADMINISTRATOR:LANE HERMOSILLOFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: 199DATE:
11/08/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Assistant Administrator, Natalie CarlborgTIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with Assistant Administrator, Natalie Carlborg and Health Services Director, Stacy Tinoco and discussed the purpose of the visit, to follow up on a self reported incident.

During today's visit, LPA briefly toured the facility, requested records, and interviewed staff and residents. The facility self reported an incident involving Resident #1 (R1). On 10/27/22, R1 eloped from the facility. The facility followed their absentee notification plan and the police located R1. R1 was returned to the facility without injury.

No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Assistant Administrator, Natalie Carlborg whose signature below confirms receipt of these rights.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2022
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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