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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604684
Report Date: 05/05/2023
Date Signed: 05/05/2023 01:07:34 PM


Document Has Been Signed on 05/05/2023 01:07 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 05/05/2023 01:04 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

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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Pre-Licensing visit to observe the facility’s physical plant for compliance with Title 22, Division 6 of the California Code of Regulations and California Health & Safety Code. LPA was greeted by, identified himself to, and explained the purpose of the visit to the applicant's representatives, Vice President of Operations James Bender and Interim Administrator Natalie Carlborg.

The facility fire clearance was granted on 03/16/2023 and reflects that the facility was approved for fifty six (56) residents in total, of which fifteen (15) may be bedridden, and all may be non-ambulatory. The submitted facility sketch is consistent with the current layout of the facility.



During today’s visit, LPA, accompanied by the applicant, toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were well lit and free of obstruction and slip hazards. Resident bedrooms allowed for easy passage and contained the required furnishings. Toilets, sinks, and showers were in working order. The facility’s ambient internal temperature was 69 F. Water temperature at taps accessible to residents were sampled and found to be compliant: Room #102 was 118.8 F, Room #105 was 116.8 F, Room #205 was 105.6 F, Room #206 was 109.4 F, Room #304 was 108.5 F, Room #305 was 106 F, Room #402 was 111.4 F, and Room #405 was 116.1 F.

The facility has enough linens, hygiene supplies, cooking and dining supplies, and perishable and non-perishable food for future resident use. All kitchen appliances were in working order. Refrigerator #1 temperature was 38.1 F, and Refrigerator #2 temperature was 38 F. Freezer temperature was -7 F.


[CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GROSSMONT GARDENS MEMORY CARE
FACILITY NUMBER: 374604684
VISIT DATE: 05/05/2023
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[CONTINUED FROM LIC 809]

The facility has sufficient space and equipment to facilitate laundry, visitation, meetings, and resident activities. The facility has locked areas for storage of medication and confidential resident and staff records. No pools or bodies of water were observed on the premises. There were no toxic chemicals/poisons, fireplaces, or open-faced heaters accessible to residents. Per the applicant, no firearms or ammunition are or will be stored at the facility.

Smoke alarms, carbon monoxide detectors, emergency lighting, and facility telephone were all operational. Fire extinguishers were professionally inspected/serviced within the last 12 months. Complete first aid kits were present. Required licensing postings were observed in visible areas of the facility.

The items reviewed were complaint with Title 22, Division 6 of California Code of Regulations and California Health & Safety Code. The applicant passed the pre-licensing inspection.

LPA also provided the Component III Training during today’s visit. Bender and Carlborg were advised that the facility’s application is pending management final review and approval.

An exit interview was conducted with the applicant's representatives, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 05/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/05/2023
LIC809 (FAS) - (06/04)
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