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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 10/27/2025
Date Signed: 10/27/2025 04:06:29 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
10/03/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251003015815
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: 374DATE:
10/27/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Associate Executive Director,Lynn TorinoTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not seek medical attention for a resident in care.
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 herself and disclosed the purpose of the visit to Lynn Torino, Assosiate Executive Director.

On 10/02/2025, it was alleged that staff failed to seek medical attention for a resident in care. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, the resident’s responsible party, and a review of resident records.

(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)
Page: 1 of 2
Control Number 08-AS-20251003015815
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 form LIC9099)

Regarding the allegation that staff did not seek medical attention for a resident in care. Mores specifically, that Resident #1(R1), who had a suprapubic catheter, experienced severe pain and made multiple requests for assistance, which were ignored by staff therefore R1 had to call emergency services to get help. Staff interview revealed that the resident was admitted on 09/19/2025, transferred to another building on 09/25/2025, and hospitalized on 09/28/2025. Staff confirmed R1 called emergency services due to suicidal ideation, not pain. Resident representative interview and care notes revealed that the responsible party was contacted by the facility on 10/02/2025. They also confirmed the resident called police due to suicidal thoughts and not due to pain. Records review revealed no documentation of complaints related to catheter pain. The Medication Administration Record (MAR) showed PRN Tylenol was administered on 09/20, 09/21, and 09/22 for general pain and discomfort. The resident was also receiving antibiotics for a UTI and Gabapentin three times daily for nerve pain. Care notes reflected no catheter-related complaints.

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 Associate Executive Director,Lynn Torino. A copy of this report and Licensee's Rights (LIC 9058 03/22) were provided and their signature on this report confirms receipt of the Licensee Rights.
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)
Page: 2 of 2