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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 10/17/2025
Date Signed: 10/17/2025 04:38:31 PM

Substantiated


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
01/11/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20240111095638
FACILITY NAME:GROSSMONT GARDENS SENIOR LIVINGFACILITY NUMBER:
374604675
ADMINISTRATOR:JONES, REGINALDFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: 373DATE:
10/17/2025
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Executive Director Chris NealeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Facility did not maintain hot water for residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst LPA Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced themselves and disclosed the purpose of the visit to Executive Director Chris Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review.

On January 11, 2024, it was alleged that the facility did not maintain hot water for residents.
More specifically, reporting party (RP) reported that residents often did not receive showers due to a lack of hot water, an issue ongoing since November 2023.

Continued on LIC 9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
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 5
Control Number 08-AS-20240111095638
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: 10/17/2025
NARRATIVE
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 Continued from LIC9099)

Staff interviews revealed that hot water sometimes runs out during shower times, requiring staff to stop showers or sometime provide bed baths. Resident interviews confirmed that water temperatures were inconsistent, with some residents reporting cold showers. Water temperature readings were taken in 13 resident rooms across four buildings. Of those, 12 out of 13 rooms had hot water temperatures within the regulatory range of 105°F to 120°F. However, hot water was not consistently maintained within the required range, as confirmed by resident and staff interviews, which included missed bathing opportunities due to a lack of hot water temperature in showers.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation(s) occurred and are therefore substantiated.

Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with Executive Director Chris Neale, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
01/11/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20240111095638

FACILITY NAME:GROSSMONT GARDENS SENIOR LIVINGFACILITY NUMBER:
374604675
ADMINISTRATOR:JONES, REGINALDFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: DATE:
10/17/2025
UNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Executive Director Chris NealeTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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-Staff did not treat residents with dignity
-Staff did not assist resident with showering
-Staff did not meet resident's dietary needs
-Staff did not serve resident food of good quality
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 Chris Neale. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, and records review.

On January 11, 2024 it was alleged Staff did not treat residents with dignity and staff did not assist resident with showering. More specifically, RP reported that a caregiver yelled at a resident, threw a diaper at them, and refused to provide water. RP also reported that the same caregiver refused to assist another resident with showering due to their incontinence issues. Staff interviews revealed that no staff reported directly witnessing Staff #1 yelling at or mistreating residents. Some staff described Staff #1 as generally cooperative and helpful, while others noted concerns about her responsiveness and work ethic. Staff also reported interpersonal tension between Staff #1 and another employee, which may have contributed to conflicting perceptions of her conduct.(Continued on LIC 9099)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20240111095638
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: 10/17/2025
NARRATIVE
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(Continued on LIC 9099C)

Resident interviews revealed that one resident reported concerns regarding Staff #1’s tone and responsiveness. Other residents interviewed described Staff #1 as helpful and did not express concerns about her conduct.

Department records review revealed no formal complaints or disciplinary actions against Staff #1. However, the lack of interviews with Residents #1 and #2 limits the department’s ability to fully assess this allegation.
This allegation is unsubstantiated due to insufficient evidence.


It was also alleged, staff did not meet residents’ dietary needs or serve food of good quality. More specifically, the Reporting Party (RP) stated that Resident #2, who is on a regular diet, was served pureed food, that portion sizes were inadequate, and that a resident was served half a hot dog on molded bread. The RP also stated that residents were not provided snacks between meals.
Staff interviews revealed that portion sizes had recently been adjusted and that food is sometimes softened for easier chewing. Staff acknowledged occasional errors in diet type, particularly with new staff. Some staff described the food as mushy or cold, but noted that seconds were available upon request.
Resident interviews revealed concerns about small portion sizes and food temperature. Some residents reported being able to request additional servings, though delays were noted.
Department records review revealed that the facility uses measured scoops for portion control and a photo of a food sample from January 2024 showed balanced meals. A list of snack items available for purchase from the facility’s store was also reviewed. The concern regarding diet type mismatch could not be verified due to the lack of documentation or interview with Resident #2.
This allegation is unsubstantiated due to insufficient evidence.


Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Chris Neale, 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: 10/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20240111095638
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/02/2025
Section Cited
CCR
87303(a)(2)
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Based on observation, interviews with staff and residents, and water temperature readings conducted by the Department, the licensee failed to ensure that hot water was maintained between 105°F and 120°F in resident-use areas, as required
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Licensee agreed to check water tempratures in common showers weekly for 30 days starting on 10/20/25. POC will be provided to LPA by 12/2/2025
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Based on interview and record review, the licensee did not comply with the section cited above as the facility did not have hot water for multiple idays which posed a potential health and safety risk to (319) of (319) of residents in care at time of complaint.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5