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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604684
Report Date: 08/10/2023
Date Signed: 08/10/2023 04:13:28 PM


Document Has Been Signed on 08/10/2023 04:13 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:AYERSMAN, JENNIEFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:56CENSUS: 49DATE:
08/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Acting Executive Director, Natalie CarlborgTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Marisela Garcia-Centeno made a Case Management visit to follow-up on an incident report. LPA identified herself and was granted entry by Nia Colman, Receptionist. LPA stated the purpose of the visit with Natalie Carlborg, Acting Executive Director.

A Incident Report was received by Community Care Licensing (CCL) on August 8, 2023, informing that Resident #1 (R1) [staff was provided an LIC 811 that identifies the resident] sustained multiple injuries of unknown source.

During today's visit, LPA Garcia-Centeno conducted a health and safety check and collected R1's records. No health and safety violations were observed during the today's visit.

An exit interview was conducted with Acting Executive Director, Carlsborg to whom a copy of this report, and LIC811 Confidential Names report and the appeal rights (LIC9058 01/16), were provided at the end of the visit.
SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) -76-2317
LICENSING EVALUATOR NAME: Marisela Garcia-CentenoTELEPHONE: (619) 323-4834
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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