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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604675
Report Date: 10/04/2024
Date Signed: 10/04/2024 11:33:23 PM

Document Has Been Signed on 10/04/2024 11:33 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME:GROSSMONT GARDENS SENIOR LIVINGFACILITY NUMBER:
374604675
ADMINISTRATOR/
DIRECTOR:
JONES, REGINALDFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 425CENSUS: 376DATE:
10/04/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Executive Director, Reginald JonesTIME VISIT/
INSPECTION COMPLETED:
12:55 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) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with Executive Director, Reginald Jones to discuss the purpose of the visit..

Today's visit was in response to a timely self reported incident that occurred on 08/24/24 involving Resident #1 (R1) and Staff #1 (S1). The incident report stated S1 hit R1 four (4) days prior on 08/21/24 for refusing medication. The facility assessed R1 and there were no injuries. The Executive Director met with R1, R1's responsible party to discuss the incident and unpaid rent. After the incident was reported, the facility implemented a two (2) persons assist required for all care and medication pass to ensure witnesses present for all care for R1. S1 denied the allegation and stated R1 refuses medication regularly but there has never been an issue of abuse. R1's Medication Administration Record confirmed R1 regularly refuses medications. It was also reported the incident occurred 08/21/24 and/or 08/23/24, conflicting statements were made about the date of the incident. Resident interview indicated not being aware of the incident and never witnessing S1 hit R1. The facility observed R1 having increased confusion and scheduled an appointment for R1 with R1's physician and a psychologist. R1 moved out of the facility on 09/14/24 with an outstanding balance.

No deficiencies were observed or cited during today's visit. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Staff #1]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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