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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 10/20/2023
Date Signed: 10/20/2023 04:42:50 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/28/2023 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20230828154350
FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:AYERSMAN, JENNIEFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:56CENSUS: 52DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Executive Director, Suzette JohnsonTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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Staff interfere with residents' sleep
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Executive Director, Suzette Johnson.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff interfered with residents’ sleep by waking them up early to get them ready for the day. Outside source interviews revealed the NOC shift, which works 10pm-6am was waking the residents up between 3:30am-4:30am. It was reported the NOC shift were getting residents up and ready for the day and taking them to the common/dining room area where the residents were falling asleep at the tables. Evidence obtained revealed the residents were tired and falling asleep in the dining room area waiting for breakfast, which didn’t start until 7:30am. The Executive Director’s (ED) interview revealed there were approximately eighteen (18) residents that wake up early and the NOC shift assists those residents first. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
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 5
Control Number 08-AS-20230828154350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GROSSMONT GARDENS MEMORY CARE
FACILITY NUMBER: 374604684
VISIT DATE: 10/20/2023
NARRATIVE
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The ED also stated there was one (1) caregiver and one (1) Medication Technician on NOC shift, and an AM staff that starts at 5:00am to assist NOC shift for one (1) hour before their shift ends.

Staff interviews revealed it’s impossible to get all multiple up by breakfast if they start at 5:00am. Therefore, staff must start waking residents up as early as 3:00am to fulfill the facility’s requirement of getting the residents up and ready. Staff interviews confirmed they wake the residents up at 3:00am-3:30am to get them ready and the residents are placed in the dining room area and are falling asleep, while they wait for breakfast to be served. Residents sleep is being interfered by staff due to waking up as early as 3:00am to get ready for a 7:30am breakfast.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation was found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Suzette Johnson whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 08-AS-20230828154350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: GROSSMONT GARDENS MEMORY CARE
FACILITY NUMBER: 374604684
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed
Type B
11/03/2023
Section Cited
CCR
87468.1(a)(2)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
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Executive Director stated an In-service will be conducted on Personal Rights to include ensuring residents sleep is not interered with. ED also stated additional staff has been hired for the NOC shift.
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Based on interviews the licensee did not ensure residents had comfortable accommodations for 10 out of 52 [R1-R10] residents in care which posed a potential health and personal rights risk to residents.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
08/28/2023 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20230828154350

FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:AYERSMAN, JENNIEFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:56CENSUS: 52DATE:
10/20/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Executive Director, Suzette JohnsonTIME COMPLETED:
03:10 PM
ALLEGATION(S):
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9
-Staff do not assist residents with bathing
-Staff do not maintain the facility in clean condition
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegation. LPA met with Executive Director, Suzette Johnson.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff do not assist residents with bathing. The Executive Director explained all residents receive two (2) showers per week or more according to their Admission Agreement. Residents have a shower schedule and are showered by the AM and PM shifts. Outside source interviews confirmed residents are being showered and cleaned. Staff interviews confirmed residents are showered based on their shower schedule. However, some residents are showered more due to bowel accidents. Staff also explained some residents are naturally sweaty and have an odor, which is their baseline. Due to residents showering twice a week, it’s possible some residents have an odor but are being showered. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20230828154350
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GROSSMONT GARDENS MEMORY CARE
FACILITY NUMBER: 374604684
VISIT DATE: 10/20/2023
NARRATIVE
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It was also alleged staff do not maintain the facility in clean condition. It was reported Room #101’s carpet had blood stains and other carpets were dirty as well and not being shampooed or cleaned. On 09/06/23, LPA observed Room #101 and observed stains on the carpet along with a strong odor. The odor was intense causing the LPA to have to exit the room quickly. LPA observed other resident rooms and discovered stains and strong odors. LPA also observed all resident hallways had new flooring as the carpets were already replaced. Staff interviews revealed they had gotten used to the smell/odors, which were caused by the old carpets. Staff also confirmed the carpets were being replaced by the new owners. The Executive Director’s (ED) interview revealed the carpets were not in clean condition and needed to be replaced. The ED explained the facility had new ownership and she was new as well but was already working on replacing all the carpets with flooring. The ED explained there was a delay with replacing all the carpets with flooring due to some issues with the contractor. However, everything was now on track and Room #101’s carpet was next on the list to be replaced. All residents have a Major Neurocognitive Disorder and did not witness odors in their rooms. The ED provided proof of documentation that all resident carpets were being replaced with flooring. In addition, the ED also provided documentation to show the timeline and delays with the contractors. The ED was able to prove the work began when they took over ownership, and time was needed to replace all the carpeting. Today, LPA confirmed all residents room carpets have been replaced with flooring.

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 are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Suzette Johnson whose signature below confirms receipt of these rights.

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5