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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604675
Report Date: 08/21/2024
Date Signed: 08/21/2024 03:32:47 PM


Document Has Been Signed on 08/21/2024 03:32 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:
374604675
ADMINISTRATOR:JONES, REGINALDFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: 376DATE:
08/21/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Executive Director, Reginald JonesTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director, Reginald Jones.

Today's visit was in response to a timely self reported incident that occurred on 07/22/24 involving Resident #1 (R1). Per the report, Staff #1 (S1) provided improper care to R1 by forcing R1 to shower, against their will. Executive Director stated S1 was suspended and later terminated on 07/29/24. S1 was terminated as it's against facility for violating a resident's personal rights.


LPA performed a facility tour/welfare check on remaining residents and collected pertinent records. No deficiencies were observed or cited during today's visit.

An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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