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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 03/03/2026
Date Signed: 03/03/2026 06:13:14 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
10/31/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251031114353
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: 60DATE:
03/03/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director Angela Scott- KapilofTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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Neglect to resident resulting in a hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced herself and explained the purpose of the visit to Executive Director Angela Scott- Kapilof.

The Department’s investigation consisted of a review of facility records, outside records, and interviews with facility staff and outside sources.

On October 31, 2025, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in the hospitalization of Resident #1 (R1). Specifically, it was reported that medication mismanagement involving duplicate clonidine patches contributed to R1’s hospitalization on April 19, 2025.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
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 5
Control Number 08-AS-20251031114353
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: 03/03/2026
NARRATIVE
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(Continued from LIC9099)

Department review of R1’s Physician’s Report shows diagnoses including cerebrovascular accident (CVA) with right sided hemiplegia, mild cognitive impairment (MCI), and dementia. R1 was admitted to the facility on March 29, 2025, following transfer from a skilled nursing facility, and required full assistance with Activities of Daily Living (ADLs).

Departments review of R1’s Medication Administration Record (MAR) shows clonidine patches were documented as applied per physician orders on 3/31/2025, 4/7/2025, and 4/14/2025. Further record review reveal that on April 19, 2025, staff observed a change of condition during the dinner hour. At 8:46 PM, staff contacted emergency services, and R1 was transported to the hospital.

Department Hospital records review dated April 19, 2025, confirm that two Clonidine patches were present and removed during R1’s admission: one patch dated 3/28/2025 located on right side of the neck and one undated patch located on the right shoulder. Department interviews with staff revealed they were unable to provide documentation explaining how the duplicate patches occurred. Under Title 22, the licensee is responsible for ensuring medications are administered as prescribed and for maintaining records and oversight to prevent medication errors. The presence of two Clonidine patches is inconsistent with physician orders and MAR documentation and demonstrates a failure to properly assist with medication administration and monitoring.

The Department has investigated the above mentioned allegation, and based on interviews and records review, the preponderance of evidence has been met. Therefore, this allegation is deemed substantiated. The following deficiency for failure to ensure proper medication assistance and oversight is cited per California Code of Regulations, Title 22, and is noted on the attached LIC 9099D page.

An exit interview was conducted with Executive Director Angela [Last Name], whose signature below confirms receipt of this report and the Licensee Appeal Rights (LIC 9058 03/22).

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
10/31/2025 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20251031114353

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: 60DATE:
03/03/2026
UNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Executive Director Angela Scott- KapilofTIME COMPLETED:
06:30 PM
ALLEGATION(S):
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9
Neglect to resident resulting in a hospitalization
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers 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, Angela Scott- Kapilof.

The Department’s investigation consisted of a review of facility and outside records, as well as interviews with staff, and outside sources.

On October 31, 2025, Community Care Licensing (CCL) received a complaint alleging that neglect resulted in hospitalization. More specifically, it was alleged that while Resident #1 (R1) was at the facility, staff failed to provide timely wound care and did not ensure appropriate equipment was in place, which allegedly resulted in the development of a Stage 4 pressure injury and subsequent hospitalization.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 08-AS-20251031114353
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: 03/03/2026
NARRATIVE
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(Continued from LIC9099)
Department record review of R1's physician report revealed R1 is diagnosed with cerebrovascular accident (CVA) with right-sided hemiplegia, along with mild cognitive impairment (MCI) and dementia. It further revealed R1 was non-ambulatory and needed full assistance with Activities of Daily living (ADL's) R1 move in date to the facility was March 29, 2025 and was transported to the facility from a skilled nursing facility.

Department records review revealed hospice services visits began July 24, 2025, with a primary diagnosis of Neurocognitive disorder along with Lewy bodies and related issues of Muscle weakness, Cerebral atherosclerosis and Abnormal weight loss. Department review of hospice documentation also included maximum assistance and up in wheelchair as and tolerated for R1. Records review further reveal hospice services for wound care began on August 8, 2025. Hospice documentation shows wound care was provided per physician orders, including daily dressing changes, multiple weekly treatments, and nutritional support.

Department review of facility records, outside source records, as well as outside source interviews and staff interviews reveal facility staff implemented non-skilled interventions within their scope and per physician orders, such as R1 sitting for periods of time in wheelchair, repositioning and offloading, and documented communication with hospice and the R1's responsible party. Department records review further reveal wound care products, nutritional supplements and medications were administered as ordered. However departments review of the Medication Administration Record (MAR) and facility care notes reveal multiple medication and nutritional supplement drink refusals by R1.

Department review of facility records, outside source records, as well as outside source interviews and staff interviews reveal R1's equipment orders per Hospice physician orders, reveal that that pressure-relief equipment, including an alternating pressure pad and a low air loss mattress, was delivered and installed prior to hospitalization in October 2025.

This agency has investigated the complaint alleging that the licensee failed to provide timely wound care and failed to ensure appropriate equipment was in place for the resident. The Department has found that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation is UNSUBSTANTIATED.

An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 03/22) was provided. Executive Director Angela Scott- Kapilof signature on this form confirms receipt of these rights.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 08-AS-20251031114353
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: 03/03/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/03/2026
Section Cited
CCR
87465(a)(4)
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87465(a) A plan for incidental medical ...(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met, as evidenced by:

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Executive Director stated an In-service will be conducted on assiting residents with self-administered medications by POC date.
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Based on record review and interviews, one (1) out of sixty (60) residents did not receive proper assistance with thier (R1) self administered medications, which posed a potential health and safety risk to residents 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 Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/03/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5