374604675-9-30-2025-08-AS-SJAB-DMJV79-20251017161046

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 09/30/2025
Date Signed: 09/30/2025 10:19:25 AM

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
05/21/2024 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20240521090426

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: 371	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director Reginald Jones		TIME COMPLETED:	10:30 AM

ALLEGATION(S):

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Staff did not respond to resident's call for assistance in a timely manner
Licensee charged fees for services that were not listed in the admission agreement
Licensee did not provide adequate food service
Staff used resident's room as a passageway to another room in the facility

INVESTIGATION FINDINGS:

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Licensing Program Analyst LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Reginald Jones.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

On May 21, 2024, it was alleged that staff did not respond to the resident's call for assistance in a timely manner. More specifically, Resident #1 (R1) and other residents experienced long delays in staff response to call buttons. R1 cited an example of a resident waiting on the toilet for an hour. The department observed the facility’s new pendant system and interviewed multiple staff and residents. Staff acknowledged that the previous system had logging issues and that response times varied depending on urgency.
(Contuned on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 08-AS-20240521090426

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: 09/30/2025

NARRATIVE

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(Continued from LIC 9099) (page 2 of 3)

Residents (R2, R3) confirmed that staff responded quickly, though R3 noted occasional delays of 15–20 minutes. Staff interviews (S1, S2) acknowledged that wait times could be longer during peak hours, but staff communicated with residents when delays occurred. While some delays were acknowledged, there is insufficient evidence to support that staff failed to respond in a timely manner in violation of regulations. The facility has since upgraded its call system, and multiple residents confirmed timely assistance.

It was also alleged licensee charged fees for services not listed in the Admission Agreement. More specifically, R1 alleged that the facility charged a $5 tray service fee and a $2.49 rent payment processing fee, neither of which was disclosed in the Admission Agreement. Review of R1’s Tenant Ledger showed no charges for tray service or rent processing fee. The Admission Agreement (Exhibit 4) clearly lists a $5 tray service fee, and staff (S6, S7) confirmed that Assisted Living Waiver residents like R1 were not charged. The $2.49 fee is a third-party processing fee disclosed during onboarding and is optional; residents may pay by check without a fee. The $5 tray fee is disclosed in the Admission Agreement, and there is no evidence R1 was charged. The $2.49 fee is not imposed by the facility and is avoidable. There is insufficient evidence to support that a tray service fee was charged, as well as the optional fee processing charge.

It was also alleged Licensee did not provide adequate food service. More specifically, residents were served cold food, had long wait times, and were denied food. LPA reviewed menus, observed meal service, and interviewed staff and residents. Menus showed multiple entrée options and a dietitian's approval. Residents (R2, R3, R4) reported satisfaction with food and timely service. Staff (S3–S5) explained that delays occurred when residents arrived early or requested tray service. LPA observed 9 trays being delivered to residents who were either bedbound or paying for the service. The facility provided adequate food service with multiple options and reasonable delivery times. No evidence supports that residents were denied meals or consistently served cold food.

(Continued on LIC 9099C page 3)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20240521090426

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: 09/30/2025

NARRATIVE

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(Continued from LIC 9099C) (Page 2 of 3)

It was also alleged that staff used the resident's room as a passageway to another room in the facility. More specifically, R1, the staff entered R1’s room through the patio door on two occasions, startling R1 and their roommate. R1 no longer resides at the facility and could not be interviewed. Staff (S6) confirmed the concern was reported and internally investigated. The department observed R1’s former room and found that the sliding door had two interior locks and no exterior access. The Executive Director confirmed that staff do not have keys to patio doors. No witnesses or documentation corroborated the alleged entry. There is no evidence to support that staff used R1’s room as a passageway. The physical layout and locking mechanisms make unauthorized entry unlikely without resident cooperation.

Based on interviews, direct LPA observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred; therefore, the allegations are UNSUBSTANTIATED.

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

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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