374604684-11-26-2024-08-AS-SJAB-DC2QQB-20241217112201

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 11/22/2024
Date Signed: 11/26/2024 10:45:23 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
11/18/2024 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20241118143000

FACILITY NAME:	GROSSMONT GARDENS MEMORY CARE		FACILITY NUMBER:	374604684
ADMINISTRATOR:	SUZETTE JOHNSON		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	64	CENSUS: 59	DATE:	11/22/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Natalie Carlborg Executive Director		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Staff are administering injectable medications

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to open an investigation on the above allegation. LPA was granted entry into the facility and met with Natalie Carlborg Executive Director, to whom LPA disclosed the reason for the visit.

Community Care Licensing (CCL) has investigated the above listed complaint allegation. The investigation consisted of review of facility records, interviews with staff and outside sources.

On November 18, 2024 Community Care Licensing (CCL) received a complaint alleging Staff are administering injectable medications.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

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-20241118143000

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 MEMORY CARE	FACILITY NUMBER: 374604684
	VISIT DATE: 11/22/2024

NARRATIVE

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Continued from LIC9099

Staff 1 (S1), (Please see confidential names on LIC811), was interviewed and verified that there were no residents given injectable medications at the facility. S1 clarified that there was a conversation of oral medications that could possibly be given to hospice residents when they were unable to swallow crushed medications. S1 clarified that it was only a topic of conversation and there were no staff members asking medication technologists to administer any injectable medications to any residents at the facility. S1 clarified again that the topic of conversation was not injectable medication. Documents were collected which revealed the facility was not providing any residents injectable medications. Staff 2 (S2) provided documentation that the facility is not currently or has not in the past administered injectable medications to any residents. The facility policy was reviewed and only licensed nurses or physicians are authorized to give residents injectable medications.

The Department investigated the above allegation and was not able to meet the preponderance of evidence standard to prove that the alleged violation occurred. Therefore, the above allegation is unsubstantiated. An exit interview was conducted with Natalie Carlborg Executive Director, and a copy of this report along with Licensee/Appeal Rights (LIC 9058 03/22) was provided at the conclusion of the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/22/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2024

LIC9099 (FAS) - (06/04)

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