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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 03/11/2026
Date Signed: 03/11/2026 03:23:47 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
03/05/2026 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20260305111816
FACILITY NAME:GROSSMONT GARDENS SENIOR LIVINGFACILITY NUMBER:
374604675
ADMINISTRATOR:NEALE, CHRISTOPHERFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:425CENSUS: 380DATE:
03/11/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Chris NealeTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff caused an injury to a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to commence a complaint Investigation and deliver a finding regarding the above allegation. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Executive Director Chris Neale.

On March 5, 2026, the Community Care Licensing Division (CCLD) received a complaint alleging that Resident #1 (R1) slipped from their wheelchair during transport and sustained an injury.

Department records review showed that the facility submitted a self-report on January 20, 2026, stating that R1 slipped from a locked wheelchair during transport and sustained a head injury requiring stitches.
Department interviews, observations, and staff demonstrations revealed that R1 had not been properly secured with the seatbelt. Staff #1 (S1) did not follow the written instructions posted inside the transport van regarding proper restraint of wheelchair residents and failed to apply the lap belt to R1. As a result, R1 slipped from the wheelchair during a stop and was injured. (Continued on LIC9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
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
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20260305111816
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 SENIOR LIVING
FACILITY NUMBER: 374604675
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/11/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type A
03/12/2026
Section Cited
CCR
87468(a)
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87468(a) – Personal RightsSpecifically:Residents have the right to be safe, comfortable, and free from harm.Failing to secure a resident during transport violates their right to safe and healthful accommodations.
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LPA verified staff drivers have knowlege on how to put bottom seatbelt on wheelchair residents. Outside source training will be conducted on 3/11/2026 andl staff will provide proof of training by POC date.
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Based on interview and observation, the licensee failed to provide safe transportation procedures resulting in R1 injusry.This posed an immediate health and safety risk to 1 out 1 residents.
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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: 03/11/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4
Control Number 08-AS-20260305111816
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 SENIOR LIVING
FACILITY NUMBER: 374604675
VISIT DATE: 03/11/2026
NARRATIVE
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(continued form LIC9099)


Based on relevant interviews observations and staff demonstration, the preponderance of evidence has been met that alleged violation 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 Executive Director Chris Neale. to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 4