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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604060
Report Date: 09/22/2020
Date Signed: 09/25/2020 04:40:21 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: 238DATE:
09/22/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:06 PM
MET WITH:Executive Director Kaitlin RudolphTIME COMPLETED:
03:07 PM
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Licensing Program Analyst (LPA) Debbie Correia conducted a Tele-Virtual Visit due to COVID-19. LPA identified herself to Executive Director Kaitlin Rudolph and we discussed the purpose of the visit.

Today's Tele-Virtual Visit is in response to the death of Resident (R1). R1 passed away while under the facility's care on September 15, 2020.

LPA conducted a Health & Safety check on this date via virtual tour. The facility was observed to be kempt, and no health or safety issues were observed on this date. LPA requested facility records on this date. No deficiencies were cited or observed at this time.

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

DATE: 09/22/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2020
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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