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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 01/29/2026
Date Signed: 01/30/2026 10:12:51 AM

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
09/13/2023 and conducted by Evaluator Amy Domingo
COMPLAINT CONTROL NUMBER: 08-AS-20230913143222
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:64CENSUS: 60DATE:
01/29/2026
UNANNOUNCEDTIME BEGAN:
10:59 AM
MET WITH:Jennie Ayersman, Executive DirectorTIME COMPLETED:
01:00 PM
ALLEGATION(S):
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Neglect of a resident resulting in serious bodily injury
Neglect of the resident resulting in a pressure injury
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 herself and disclosed the purpose of the visit to the Executive Director, Jennie Ayersman.

The Department’s investigation consisted of a review of facility and outside records, as well as interviews with staff, residents, and outside sources. On September 13, 2023, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in serious bodily injury and neglect to a resident, resulting in serious pressure injury.

Sufficient information and statements via interviews of staff were obtained to substantiate the allegation of neglect/lack of supervision on the part of the facility staff, resulting in a serious injury to Resident 1 (R1).

[Continued on LIC9099]
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
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-20230913143222
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: 01/29/2026
NARRATIVE
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[Continued from LIC9099 2 of 3]

R1 sustained unwitnessed falls on August 8, 2023, August 9, 2023, and August 12, 2023, the last causing a left femoral fracture. Medical records were obtained from the hospital, and multiple staff members were interviewed. Staff 1 (S1) was interviewed, and S1 reported that the residents, including R1, were being properly checked. Staff 2 (S2) provided contradicting information and made statements to the contrary. According to statements provided by the S3, the nocturnal shift staff have been an issue at the facility, as residents were consistently found to be saturated with urine or soiled, indicating that they were being neglected and not checked on as required. In addition, the proper response time of the falls sustained by R1 appears to have been delayed due to staff not adhering to scheduled safety checks.

On September 13, 2023, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in serious bodily injury to a resident, resulting in a pressure injury. R1 sustained a left femoral fracture due to a fall at the facility on August 12, 2023. A review of historical diagnosis, as of September 30, 2023, does not list the pressure sore for R1.

August 22, 2023, encounter notes have R1 with a left femoral fracture and have a leg immobilizer on. R1's sacrum and buttocks were reported as being clear with no skin breakdown. R1 was noted as being unable to communicate all their needs and was unable to report the location of their pain. R1 was placed in a splint brace to mobilize their leg for recovery. Written instructions were included with their hospital discharge documents as to the care and monitoring of the splint brace and leg. Statements obtained from interviews with staff tend to show that the splint brace on R1’s leg was not properly monitored or adjusted as instructed on the discharge document. Due to the lack of appropriate monitoring, the splint brace caused a stage III pressure injury on R1's ankle. Medical records documenting the pressure injury were obtained from the hospital. Outside source 1 (OS1) was interviewed, and advised that R1 was susceptible to pressure injuries due to their age and condition.

On September 8, 2023, a video encounter notes R1 was brought in on August 12, 2023, for an unwitnessed fall and was found to have a closed non displaced fracture at their left femur. R1 was advised not to bear

[Continued on LIC9099]
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 08-AS-20230913143222
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: 01/29/2026
NARRATIVE
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[Continued from LIC9099C 3 of 3]

weight for six weeks. Further noted, per Staff 3 (S3), skin is good, no pressure sores.
On September 12, 2023, R1 was brought into the Emergency Department after the care facility staff discovered a new left ankle pressure ulcer from wearing their left femoral fracture brace. The emergency Department documented that R1 was brought in and diagnosed with a stage 3 pressure injury on their left ankle. R1 fractured their femur 5 weeks ago and has been wearing a removable brace. A pressure ulcer was discovered today at the facility. S3 reported that they did not take off or adjust the brace until today, when they noticed the new pressure injury.

Based on relevant interviews and records review, the preponderance of evidence has been met that the alleged violation(s) occurred and are therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). At this time, per Health and Safety Code Section 1569.2(c), an additional civil penalty assessment is under review by the Program Administrator of the Community Care Licensing Division. A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Jennie Ayersman, Executive Director, 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: 01/29/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20230913143222
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: 01/29/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
01/30/2026
Section Cited
CCR
87465(a)(1)
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Facilities must ensure a plan for medical care, and residents receive the necessary medical care for their conditions and needs.
This requirement was not met, as evidenced by:
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 Licensee agrees to provide LPA with documentation of training dates within 24 hours by an approved vendor.
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Based on observations, interviews, and records reviewed, one (1) out of sixty (60) residents did not receive the necessary medical care for their (R1) condition, which posed an immediate safety risk to persons in care.
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Under Appeal
Type A
01/30/2026
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include:(4) Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing...
This requirement was not met as evidenced by:
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 Licensee agrees to provide LPA with documentation of training dates within 24 hours by an approved vendor.
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Based on records and interviews, the licensee did not provide personal assistance and care as needed in one (1) of eighty-seven (87) persons in care (R1), which posed an immediate safety risk to persons 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: 01/29/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4