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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 05/14/2025
Date Signed: 05/21/2025 11:51:15 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
11/05/2024 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20241105102141
FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:64CENSUS: 59DATE:
05/14/2025
UNANNOUNCEDTIME BEGAN:
01:05 PM
MET WITH:Natalie Carlborg, Executive DirectorTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff did not meet resident's incontinence needs.
Staff did not meet resident's food service needs.
Staff did not meet resident's hygiene needs.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings of the complaint investigation. LPA introduced herself, was granted entry, and met with Natalie Carlborg, Executive Director, to whom she disclosed the reason for the visit.

During the investigation, LPA Domingo conducted a facility tour, conducted interviews, and collected pertinent resident records. On January 5th, 2023, Community Care Licensing (CCL) received a complaint alleging that staff did not meet residents' incontinence needs. LPA observed incontinence supplies at the facility in the bathrooms and in the residents' rooms, and storage areas. Interviews revealed that staff assist the residents with changing and cleaning after using the bathroom, and if the resident soiled their adult brief due to incontinence. Interviews revealed that the residents take showers on regular assigned shower days or as needed.

(Continued on LIC9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
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-20241105102141
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: 05/14/2025
NARRATIVE
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(Continue from LIC9099)

Interviews revealed staff did not let the residents stay in a soiled brief, and staff will provide incontinence care as needed. LPA observations revealed a sufficient amount of incontinence products in the facility. LPA also observed that the facility was not malodorous of urine or feces. LPA Domingo did not observe any residents during the visit who needed incontinence care.

It was alleged that staff did not meet residents' food service needs. Interviews revealed that the staff assist residents with meals as needed and when the residents' service plans stated that there is a need to assist the residents during meals. The residents have meals in the room when requested. Records reviewed that R1 was independent with meals. R1 was able to push the meal tray and move the tray on their own. Records reviewed showed meals were provided and delivered to R1's room upon request.

The resident was admitted on October 16, 2024, and previously resided at the family residence. On November 13, 2024, a Safety/Wellness check, police came, and they did not file a report, nor were there any findings that R1 needed any assistance. The resident moved out of the facility on November 15, 2024, per family request, and no known address was shared with the facility.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements, and the 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 03/22), was provided to Natalie Carlborg, Executive Director whose signature below confirms receipt of these rights.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2