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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604684
Report Date: 09/24/2024
Date Signed: 09/24/2024 05:54:57 PM


Document Has Been Signed on 09/24/2024 05:54 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:SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:64CENSUS: 57DATE:
09/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Natalie Carlborg Executive DirectorTIME COMPLETED:
11:25 AM
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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 Natalie Carlborg Executive Director.

Today’s visit was in response to an incident which licensee self reported via an LIC624 Incident Report. The report described Resident #1 (R1 – See LIC811 Confidential Names List for identification of R1)…

LPA Domingo interviewed staff, and obtained copies of pertinent facility records. No deficiencies were observed or cited on this date.

An exit interview was conducted, and a copy of this report and Licensee Rights LIC 9058 (03/22)  were left with the Executive Director, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Simon JacobTELEPHONE: (619) -76-2306
LICENSING EVALUATOR NAME: Amy DomingoTELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:
DATE: 09/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/24/2024
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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