374604684-10-8-2025-08-AS-SJAB-DMGUWF-20251015155640

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 10/08/2025
Date Signed: 10/08/2025 11:11:24 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
07/17/2023 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20230717111145

FACILITY NAME:	GROSSMONT GARDENS MEMORY CARE		FACILITY NUMBER:	374604684
ADMINISTRATOR:	AYERSMAN, JENNIE		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	64	CENSUS:	DATE:	10/08/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Natalie Carlborg		TIME COMPLETED:	11:15 AM

ALLEGATION(S):

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- Staff did not meet incontinence care needs of residents
- Staff did not meet resident's bathing needs
- Staff did not ensure residents had clean linens
- Insufficient staff to meet the care needs of residents

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver investigative findings. Upon arrival, LPA was greeted by Executive Director Executive Director Natalie Carlborg. LPA identified herself and explained the purpose of the visit.

Community Care Licensing (CCL) initiated an investigation in response to a complaint received on July 17, 2023, that staff did not meet the incontinence care needs of residents, staff did not meet residents' bathing needs, staff did not ensure residents had clean linens and insufficient staff to meet the care needs of residents

To investigate these allegations, the Department conducted an onsite facility inspection, reviewed facility records and medical documentation, and conducted multiple interviews with facility staff, residents, and external sources. (continue at LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

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-20230717111145

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: 10/08/2025

NARRATIVE

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(Continued from LIC9099) ( Page 2 of 3)

It was alleged that staff did not meet the incontinence care needs of residents. More specifically, the Reporting Party (RP) reported that during the night, they found seven residents double diapered and very wet when providing incontinence care. RP stated that despite reporting this to management, the issue persisted. Staff interviews revealed that incontinence care was provided per schedule and that double-diapering was not a standard practice. Resident interviews revealed no concerns regarding incontinence care. Records review revealed that incontinence care schedules and staffing assignments were consistent with regulatory requirements. The Department’s observations revealed that residents were not observed in soiled or double-diapered conditions during visits conducted around the time of the allegation.

It was further alleged that staff did not meet residents’ bathing needs. More specifically, RP stated that staff were not assisting residents with showers. Staff interviews revealed that showers were being provided according to the facility’s schedule. Resident interviews revealed no concerns regarding bathing assistance. Records review revealed that shower schedules and hygiene documentation were consistent with regular bathing practices. The Department’s observations revealed that residents appeared clean and well-groomed during visits conducted around the time of the allegation.

It was further alleged that staff did not ensure residents had clean linens. More specifically, it was alleged that management instructed staff not to change soiled linens for two to three days due to excessive laundry. Staff interviews revealed that while one staff member reported delays in linen changes due to laundry volume, no staff confirmed that this was a directive from management. Resident interviews revealed no concerns regarding the cleanliness of their bedding. Records review revealed that laundry schedules and linen inventory logs for July 2023 did not reflect any service delays. The Department’s observations revealed that resident beds had clean linens with no visible soiling or odors during visits conducted around the time of the allegation.

(Continued on LIC9099C)

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230717111145

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: 10/08/2025

NARRATIVE

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Continued from LIC9099C) (Page 3 of 3)

It was further alleged that there was insufficient staff to meet the care needs of residents. More specifically, RP stated that the facility was understaffed, particularly during the night shift, resulting in unmet care needs, including management of behavioral issues. Staff interviews revealed that while there were occasional challenges during shift transitions, particularly between evening and night shifts, these were temporary and did not result in unmet care needs. Staff also reported that management was responsive and made adjustments when necessary. Resident interviews revealed no reports of unmet care needs or delays in receiving assistance. Records review revealed that staffing schedules for the relevant timeframes were consistent with the facility’s Plan of Operation and regulatory staffing requirements. The Department’s observations revealed that staff were present and engaged with residents, and no immediate health or safety concerns were noted during visits conducted around the time of the allegation.

Based on interviews, direct Department observations, and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred. Therefore, the allegations are determined to be UNSUBSTANTIATED.

An exit interview was conducted with Executive Director Natalie Carlborg, to whom a copy of this report and the Licensee/Appeal Rights (LIC 9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025

LIC9099 (FAS) - (06/04)

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