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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604060
Report Date: 10/18/2022
Date Signed: 10/19/2022 08:42:43 AM


Document Has Been Signed on 10/19/2022 08:42 AM - 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: 201DATE:
10/18/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Lane HermosilloTIME COMPLETED:
03:14 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with Executive Director, Lane Hermosillo and discussed the purpose of the visit, to follow up on self reported incidents.

During today's visit, LPA briefly toured the facility, requested records, and interviewed staff. The facility self reported three incidents. One incident was reported on 04/26/22, which involved Resident #1 and Staff #1. The second incident occurred on 06/14/22 and involved Resident #2 falling and sustaining injuries. The third incident involved Resident #3 on 10/11/22 having multiple falls and sustaining an 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 Executive Director, Lane Hermosillo 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: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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