374604675-12-17-2025-08-AS-SJAB-DPNTT4-20251224140003

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 12/16/2025
Date Signed: 12/17/2025 12:02:21 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
06/25/2025 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250625121958

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: 380	DATE:	12/16/2025
		UNANNOUNCED	TIME BEGAN:	08:30 AM
MET WITH:	Chris Neale Executive Director		TIME COMPLETED:	10:54 AM

ALLEGATION(S):

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Staff did not prevent a resident from attempting to sexually assault another resident while in care
The staff did not prevent a resident from invading another resident's privacy
Staff are causing a resident to fall while in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director, Chris Neale.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources.

On 6/5/25, the department received a complaint alleging that a resident attempted to sexually assault another resident and that staff failed to intervene or prevent the incident. Staff interviews revealed that staff have not witnessed R2 going into R1's room at any time. Staff stated that R2 has never exhibited inappropriate behaviors while at the facility. Staff interviews revealed that R1 has a history of paranoia and delusional thoughts.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

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-20250625121958

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: 12/16/2025

NARRATIVE

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Outside source 1 (OS1) was interviewed and confirmed that the facility had communicated behavioral concerns and interventions with R1. OS1 stated that R1 has been having increased behaviors, and the facility staff have been meeting with OS1 with plans of moving R1 to the assisted living area of the facility. OS1 does not believe any resident entered R1's room or attempted any inappropriate behaviors with R1.Records review showed that the facility had documented behavioral plans, and a plan was in place to move R1 to a higher level of care. Records reviewed verified that R1 had a diagnosis of advanced Parkinson's, increased confusion, delusional thoughts, and paranoia. LPA observations confirmed that staffing ratios and supervision practices were in place and consistent with regulatory requirements.

On 6/25/25, it was reported that the resident entered another resident’s room without permission and staff failed to prevent the invasion of privacy. Staff interviews revealed that staff were aware of the resident’s behavior and had implemented monitoring and redirection protocols. Staff interviews revealed that R2 was never seen entering R1's room at any time. Outside source interviews did not provide evidence that privacy rights were violated. Records review showed that the facility had policies in place regarding resident privacy, and staff followed procedures. LPA observations confirmed that room assignments and supervision were appropriate, and there were care plans in place to address R1's increased behaviors.

On 6/25/25, it was alleged that staff actions contributed to a resident falling.Staff interviews indicated that the resident had a documented fall risk and staff were following the care plan. There were no recent falls documented or witnessed.

OS1's interview confirmed that R1 had a history of falls due to medical conditions. OS1 and the facility staff plan of care was to move R1 to a higher level of care. The move to the assisted living area provided closer supervision. OS1 was supportive with the move from the independent living area to the assisted living area. Records review showed that fall prevention protocols were in place.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were given to Executive Director, Chris Neale.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2025

LIC9099 (FAS) - (06/04)

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