374604675-6-19-2025-08-AS-LTEZ-DPUSCF-20251230124527

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 06/19/2025
Date Signed: 06/19/2025 08:35:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2025 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20250307104318

FACILITY NAME:	GROSSMONT GARDENS SENIOR LIVING		FACILITY NUMBER:	374604675
ADMINISTRATOR:	JONES, REGINALD		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	425	CENSUS: 359	DATE:	06/19/2025
		UNANNOUNCED	TIME BEGAN:	03:41 PM
MET WITH:	Executive Director, Reginald Jones		TIME COMPLETED:	03:50 PM

ALLEGATION(S):

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Staff did not treat resident with dignity
Staff did not assist resident with hygiene needs
Staff did not assist with laundry service

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Executive Director, Reginald Jones.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not treat resident with dignity, staff did not assist resident with hygiene needs, and staff did not assist with laundry service. All allegations are in reference to Resident #1 (R1). Outside Source #1 (OS1) reported that on 03/06/25, a facility staff member threw a blanket at R1 and was rude to R1. On 03/13/25, LPA reviewed video footage of the encounter with facility staff and R1 that occurred on 03/05/25. The video revealed a staff wheeling R1 in their wheelchair to a common area and left R1 with OS1, who was going to transport R1 to an appointment. The staff member returned briefly and gently wrapped R1 in a blanket and bent down and kissed R1 on the cheek. There was no footage of the blanket being thrown at R1 or R1 not being treated with dignity. Continued on an LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250307104318

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GROSSMONT GARDENS SENIOR LIVING	FACILITY NUMBER: 374604675
	VISIT DATE: 06/19/2025

NARRATIVE

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OS1 also reported that on 03/06/25, R1 had crusty eyes, body odor, poor dental, clothes soiled, smelled of urine, and dried feces on their clothing. Staff interviews confirmed R1 was not presented that way to OS1 and was clean. Staff stated the police arrived at the facility and observed R1’s clothing, there were no feces observed on R1’s clothing. Additional staff interviews confirmed R1 was non-compliant with care by resisting care from facility staff. Staff explained R1 was a two person assist due to R1 being combative and injuring staff while providing care.

An interview with outside source #2 (OS2), confirmed R1 was non-compliant with care. R1’s interview was unsuccessful due to their diagnosis of a Major Neurocognitive Disorder. A review of the facility’s Observations/Daily Logs dated January, February and March of 2025, all indicated R1 was injuring staff while they provide care and R1’s non-compliance to care. Staff explained that when R1 is combative they give R1 time to calm down and will return and provide care. Staff confirmed R1’s needs are met. OS2’s interview stated R1’s laundry is laundered by R1’s family. The family takes R1’s clothing to their house, launders it and brings it back to the facility, either the same the week or the following week. The facility launders R1’s whites, linens and towels. Resident interviews confirmed they are treated with dignity, their hygiene needs are met, and they receive laundry services from staff.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. 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]

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2025

LIC9099 (FAS) - (06/04)

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