374604675-10-27-2025-08-AS-SJAB-DN62AK-20251105161340

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 10/27/2025
Date Signed: 10/27/2025 02:45:58 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
05/20/2024 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20240520104600

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: 374	DATE:	10/27/2025
		UNANNOUNCED	TIME BEGAN:	09:11 AM
MET WITH:	Assistant Executive Director Lynn Torino		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not ensure resident's blood sugar was checked
Staff retaliated against resident in care
Staff did not treat resident with dignity and respect

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.

On May 20, 2024, Community Care Licensing (CCL) received a complaint alleging that staff failed to provide appropriate care to Resident #1(R1), including not checking their blood sugar, retaliating against them after they filed a complaint, and treating them without dignity and respect.

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

(Continued on LIC9099)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025

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-20240520104600

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: 10/27/2025

NARRATIVE

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(Continued from LIC9099)

It was alleged that staff did not ensure the residents’ blood sugar was checked. More specifically, it was alleged that staff failed to check the R1's blood sugar. Staff interviews revealed that BG checks were offered by physician orders and refusals were documented. Resident interview revealed that R1 often refused checks due to discomfort or frustration with staff. Reporting Party (RP) interview confirmed the resident reported missed checks but also acknowledged R1 refusal. Records review showed consistent documentation of refusals by R1 and a temporary supply issue that was addressed. LPA observations confirmed that staff were aware of the care plan and continued to offer services.

It was also alleged that staff retaliated against residents in care. More specifically, it was alleged that staff retaliated against the resident after R1 filed a complaint. Staff interviews denied any retaliatory behavior and stated that care was provided consistently. The resident interview revealed that R1 believed staff refused to check R1's sugar in retaliation, but R1 also admitted to avoiding the medication room. The RP interview confirmed R1's belief but acknowledged R1's behavioral challenges. Records review did not show any change in care following the complaint. The department's observations revealed no evidence of retaliation.

It was also alleged that staff did not treat residents with dignity and respect. More specifically, staff made inappropriate comments about R1's physical condition. Staff interviews denied making disrespectful comments and described using calm redirection. R1's interview revealed that R1 felt disrespected by a comment from staff, but no witnesses could be identified. The RP interview confirmed the R1's report but could not provide verifiable witnesses. Records review did not reflect any inappropriate staff behavior. The department observations confirmed professional conduct by staff.

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 Assistant Executive Director Lynn Torino, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2025

LIC9099 (FAS) - (06/04)

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