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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604675
Report Date: 05/07/2024
Date Signed: 05/09/2024 08:24:10 AM


Document Has Been Signed on 05/09/2024 08:24 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:
374604675
ADMINISTRATOR:JONES, REGINALDFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: 351DATE:
05/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Executive Director, Reginald JonesTIME COMPLETED:
12:40 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit.

The facility self-reported an incident that occurred on 04/28/24 involving Resident #1 (R1). R1's Physician's Report dated 05/05/23, indicated R1 is not allowed to leave the facility unassisted. The report stated at 9:20pm staff were unable to locate R1 during routine rounds. A room to room search was initiated but unsuccessful. R1 was last observed by staff at 9pm walking around by the activities room. R1's responsible party was notified, and the La Mesa Police department responded and assisted with the search. At 11:45pm the community received a phone call from someone stating they encountered R1 and R1 stated they lived at the facility. Police and paramedics responded to address given for R1's location. R1 reported they fell and had an abrasion to their forehead. Paramedics transported R1 to the hospital for evaluation. The facility reported at the hospital, there were no significant findings / injury. R1 sustained an abrasion visible to the left side of forehead and left wrist. Resident returned to the facility on 04/29/24. R1 reported they went out front to get some fresh air and then got "turned around". Staff increasing safety checks and monitoring R1. The facility has also provided R1 with a wander guard as a safety precaution. The facility followed their Absentee Notification Protocol.

No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones 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: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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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