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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 11/17/2025
Date Signed: 12/18/2025 01:32:03 PM

Substantiated


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
05/01/2025 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20250501161630
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: 62DATE:
11/17/2025
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Natalie Carlborg, Executive DirectorTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Licensee was not protecting resident from physical abuse.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Natalie Carlborg, Executive Director.

On 5/1/25 it was alleged the Licensee was not protecting resident from physical abuse. The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and records review.

Staff interviews revealed that Resident 1 (R1) was touched inappropriately by Resident 3 (R3) when R3 wandered into R1’s room. R1 was fully clothed at the time and was able to instruct R3 to leave. R3 complied and exited the room. R1 immediately reported the incident to facility staff.

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

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
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 4
Control Number 08-AS-20250501161630
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: 11/17/2025
NARRATIVE
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(Continued from LIC9099 2 of 3)

Staff interviews revealed that Resident 1 (R1) was touched inappropriately by Resident 3 (R3) when R3 wandered into R1’s room. R1 was fully clothed at the time and was able to instruct R3 to leave. R3 complied and exited the room. R1 immediately reported the incident to facility staff.

Staff also reported that Resident 2 (R2) was asleep in their room when R3 entered and inappropriately touched R2 while R2 was fully clothed. R2 instructed R3 to leave the room, and R3 complied. R2 also immediately reported the incident to staff.

Resident interview revealed R1 stated they were in their room when R3 entered without permission. R1 reported that R3 approached them and touched them inappropriately over their clothing. R1 stated they immediately told R3 to leave the room. R3 complied and exited. R1 reported feeling uncomfortable and informed staff of the incident right away. R1 stated they did not sustain any physical injuries but were upset by the incident and requested that R3 not be allowed to enter their room again.

R2 stated they were asleep in their room when they awoke to find R3 in the room. R2 reported that R3 touched them inappropriately over their clothing. R2 stated they told R3 to leave, and R3 exited the room without further incident. R2 reported the incident to staff immediately. R2 expressed concern about safety and requested that staff ensure R3 does not enter their room again.

Records review revealed R3 does not have a documented history of wandering behaviors or inappropriate behaviors. The wandering and inappropriate behavior was identified by staff and R3 was sent to the hospital for evaluation.

Incident Reports dated 4/1/25 document the two separate incidents involving R3 entering the rooms of R1 and R2 and making inappropriate physical contact. Both reports (SOC341) were completed by staff and submitted to the Community Care Licensing and the Ombudsman office. There was documentation of immediate protective measures taken to prevent recurrence, such as increased monitoring and hospitalization for evaluation.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 08-AS-20250501161630
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: 11/17/2025
NARRATIVE
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(Continued from LIC9099C 3 of 3)

Staff Communication Logs and Shift Notes from the dates of the incidents reflect proactive interventions.

Based on relevant interviews and records review, the preponderance of evidence has been met that alleged violation occurred and are therefore substantiated.  Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D).  A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Natalie Carlborg, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 08-AS-20250501161630
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/17/2025
Section Cited
CCR
87468.1(a)(3)
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Residents in all residential care facilities for the elderly shall have...the following personal rights: (3) To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature…This requirement was not met as evidence by;

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The facility agrees to conduct a training on personal rights with all staff by 12/17/2025. The facility will send LPA the sign in sheet with the training contents by 12/117/25
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Based on interviews and records reviewed licensee did not provide resident rights to two (2) of sixty three (62) persons in care which posed a potential Health and Safety risk to person in care.
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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: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4