<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604684
Report Date: 09/15/2023
Date Signed: 09/17/2023 04:05:34 PM


Document Has Been Signed on 09/17/2023 04:05 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:
09/15/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:03 PM
MET WITH:Suzette Johnson, Executive DirectorTIME COMPLETED:
01:28 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced Case Management visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Suzette Johnson, Executive Director.

Today's visit was in response to a self reported incident to the San Diego Regional Office on 09/12/2023 LPA briefly toured the facility and collected pertinent records. No deficiencies were observed or cited during today's visit.

An exit interview was conducted with Suzette Johnson, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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 1