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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604684
Report Date: 09/07/2023
Date Signed: 09/07/2023 03:30:10 PM


Document Has Been Signed on 09/07/2023 03:30 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: 50DATE:
09/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Resident Care Coordinator LaTasha GatesTIME COMPLETED:
10:45 AM
NARRATIVE
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Licensing Program Analyst (LPA) Iby Strong made an unannounced visit to conduct a Health and Safety visit. LPA identified herself and disclosed the purpose of her visit. LPA met with R
esident Service Director LaTasha Gates and discussed the purpose of the visit. Executive Director Suzette Johnson arrived shortly after.

During the visit, LPA Strong toured the facility.

On today's visit no deficiencies were cited. An exit interview was conducted and a copy of Licensee's Rights (LIC 9058 03/22) along with a copy of this report was provided to Executive Director Suzette Johnson.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Iby StrongTELEPHONE: 619-481-0846
LICENSING EVALUATOR SIGNATURE:
DATE: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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