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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604060
Report Date: 11/23/2022
Date Signed: 11/23/2022 12:09:19 PM


Document Has Been Signed on 11/23/2022 12:09 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: 220DATE:
11/23/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Administrator Lane HermosilloTIME COMPLETED:
12:15 PM
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Licensing Program Analysts (LPAs), Tammer De Los Santos and Kayla Hilario, conducted an unannounced Case Management visit. LPAs were allowed entry by receptionist and met with Administrator Lane Hermosillo and Health Services Director Stacy Tinoco. LPAs identified themselves and discussed the purpose of the visit.
Today's visit was in response to self-reported death of Resident #1 (R1). [See LIC 811 Confidential Names List for a description of R1]. R1 passed on 11/13/2022 away from the facility. LPAs conducted interviews with staff and collected records.

No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Administrator Lane Hermosillo to whom a copy of this report and an appeal rights (LIC9058 03/22) were provided via hardcopy of the conclusion of the visit.
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Kayla HilarioTELEPHONE: 619-481-0844
LICENSING EVALUATOR SIGNATURE:
DATE: 11/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/23/2022
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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