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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 02/06/2026
Date Signed: 02/10/2026 09:53:56 AM

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
12/17/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251217151827
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: 388DATE:
02/06/2026
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Executive Director Chris NealeTIME COMPLETED:
10:00 AM
ALLEGATION(S):
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Staff left a resident soiled for an extended period of time
Staff did not timely address a resident's change in medical condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced complaint visit to deliver findings on the above allegations. LPA met with Executive Director Chris Neale and discussed the purpose of the visit and elements of the complaint.

The investigation consisted of records review, interviews with facility staff, residents and resident familiy members as well and observations during an unannounced visit.

On December 17, 2025 Community Care Licensing (CCL) it was reported that staff left a resident soiled for an extended period and staff did not timely address a resident’s change in medical condition.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
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-20251217151827
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: 02/06/2026
NARRATIVE
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Continued form LIC9099)

Regarding the allegation that staff left R1 soiled for an extended period. More specifically, RP reported staff left R1 soiled for hours without assistance. Department interviews reveal that  R1 confirmed requiring staff assistance for toileting and incontinence care. R1 reported occasional delays for staff response, but clarified this is not typical, as staff usually respond within a reasonable time. R1 also stated that staff assist with bed transfers and toileting multiple times daily. Department Interviews reveal the Executive Director indicated that pendant calls are answered promptly and that the Gardens area is staffed to meet resident needs, with additional support available from the South Building if necessary. Department interviews with residents, family members, and staff did not reveal any major concerns related to staff response times or incontinence care. Some individuals noted minor delays in answering call lights; however, there was no indication of inadequate supervision. Department records review of facility documentation and records did not produce evidence of neglect or prolonged soiling. During the visit, the Licensing Program Analyst observed R1’s room and noted no foul odors or unsanitary conditions.

Regarding the allegation that staff did not timely address R1’s change in medical condition. More specifically, R1 throwing up for three days straight before nursing addressed R1. Department review of facility records reveal evaluations completed on January 18, August 6, and November 4, documenting reassessment of R1’s needs, including assistance with transfers, dressing, and toileting. Following the evaluations ED revealed that the facility encouraged R1 to relocate for closer proximity to care staff and coordinated two-person transfers when required. No evidence was presented that the facility failed to notify physicians or responsible parties of incidents. Interviews with staff and outside sources revealed no concerns regarding failure to address changes in condition.


The Department has investigated the above-mentioned allegations and based on observation, interviews, and records review, the preponderance of the evidence has not been met, therefore, these allegations are deemed unsubstantiated.

A copy of this report along with licensee rights (LIC 9058, 3/22) was provided to Executive Director Neale whose signature below verifies receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 2