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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 12/02/2025
Date Signed: 12/02/2025 05:06:29 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
12/27/2024 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20241227172739
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: 402DATE:
12/02/2025
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Executive Director Chris NealeTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff did not meet resident's needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to further investigate and 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, outside sources, and records review. On 12/27/2024, it was alleged that licensee staff did not meet residents' needs. More specifically, Resident #1 (R1) was not adequately supervised, resulting in a fall and hypothermic.

(continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
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-20241227172739
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: 12/02/2025
NARRATIVE
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(Continued from LIC9099)


Staff interviews revealed that R1 was considered independent, used a walker, and was not known to be a fall risk. Staff confirmed that safety checks were conducted in the morning and evening, as well as during the NOC shift. They further report R1 was social, independent, and regularly seen walking with her walker. They acknowledge that R1 reported and they observed cold-like symptoms the night before the incident, but no additional concerns were noted. Outside source interview confirmed that R1 was independent but had recently shown signs of weakness. The family had declined additional care services due to financial limitations. Records review showed that R1 was receiving additional safety checks as of October 2024. No prior falls were documented. LPA observations and interviews confirmed that the facility had systems in place for routine safety checks and that R1 resided in the assisted living area.

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. A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to ED Neale whose signature below verifies receipt of these right. [See LIC 811 Confidential Names List to identify Resident #1]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025
LIC9099 (FAS) - (06/04)
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