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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 12/15/2025
Date Signed: 12/15/2025 04:26:03 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
03/14/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20250314110932
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: 380DATE:
12/15/2025
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director Chris NealeTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Licensee did not ensure adequate staffing to meet resident needs
Facility staff did not meet residents bathing needs
Facility staff did not meet residents toileting needs
Facility staff did not respond to residents' call buttons in a timely manner
Staff did not provide residents with timely meals
INVESTIGATION FINDINGS:
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LPA Rodgers conducted an unannounced visit to the facility to further invisigate and deliver findings regarding the above complaint allegations. The visit was conducted via email with Executive Director Chris Neale. The Department’s investigation included unannounced facility visits, interviews with facility staff, residents, and outside sources, as well as a review of facility records.

On March 14, 2025, the Community Care Licensing Division (CCLD) received a complaint alleging the above alligations. More specifically, the Reporting Party (RP) alleged that inadequate staffing impacted residents’ care in the following areas:Bathing: missed scheduled showers; Toileting: soiled briefs not changed in a timely manner. Response to call buttons: delayed by over an hour. Meal service: delays in receiving meals, including late or forgotten room tray deliveries and missed escorts to the dining room.

(continued on LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
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-20250314110932
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: 12/15/2025
NARRATIVE
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(Continued from LIC9099) Regarding the allegations of Inadequate staffing resulting in unmet resident care needs, including bathing, toileting, and meal service. The Department interviews revealed that residents were generally satisfied with the care provided. They reported receiving timely assistance with bathing, toileting, grooming, and meals. Staff acknowledged that some residents occasionally refused care services, such as bathing or grooming, but stated that efforts were made to re-approach and provide assistance. Regarding meal service, staff confirmed that room trays were delivered after dining room service concluded, in accordance with facility policy. One outside source expressed concern about staffing levels and their potential impact on both personal care and meal delivery. However, they also noted that resident refusal contributed to missed services. The Department reviewed facility records, which showed a reduction in room tray service following administrative efforts to encourage communal dining and manage service demand. No evidence was found of systemic delays or failures in providing care or meals.

Regarding the allegation that the delayed response to resident call buttons led to unmet care. Staff reported that the facility transitioned to a new call system in early 2025, which allows staff to receive alerts and document their response times. Due to the timing of the transition, call button logs were not available for the review period. However, staffing documentation confirmed consistent coverage.  Resident interviews did not reveal concerns regarding call button response times. Residents reported that staff responded when needed and were generally attentive.

The Department conducted an in-depth review of facility documentation, including staffing schedules, timekeeping records, hygiene schedules, and care logs. The review confirmed that staff were scheduled to provide care services consistently during the period in question. Documentation showed that residents were scheduled for regular bathing and grooming services, and staff recorded completed care, refusals, and follow-up attempts. Observations made during the visit confirmed that residents appeared clean, well-groomed, and were receiving assistance. The department observations confirmed that meals were being served in a timely and organized manner. LPA observed staff responding to residents during the visit without delay.

Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director via email. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to both via E-mail.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC9099 (FAS) - (06/04)
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