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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 05/28/2026
Date Signed: 05/28/2026 04:20:10 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: 394DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Administrator Chris NealeTIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff do not ensure the residents room are properly maintained
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to Adminsitrator Neale.
The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents and LPA observations
On March 5, 2026, Community Care Licensing Division (CCLD) received a complaint alleging staff do not ensure the residents’ rooms are properly maintained. More specifiicaly, clutter and unsanitary condiations as well as lifted flooring in some rooms.
Staff interview revealed Residents #1 and #2 (R1 and R2) can be confrontational at times when approached regarding cleaning or clutter, and that room cleaning assistance is sometimes declined by the residents.Resident interview revealed both R1 and R2 stated they were willing to allow staff to help them clean their rooms and did not report refusing assistance. LPA observations revealed excessive clutter throughout the rooms, including numerous small plastic bags and personal items on the floors, thick cobwebs on lamp, food debris on the floor, stains on flooring ranging from approximately 1 inch to 10 inches, and damaged flooring in the entry to Bedroom #2 and Bathroom #2 where flooring was lifted or missing sections.
Based on relevant interviews and observatino , the preponderance of evidence has been met that the alleged violation occurred and is therefore substantiated. Deficiencies are cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099D).
A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with Administrator Neale, to whom a copy of this report, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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-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: 05/28/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/28/2026
Section Cited
CCR
87303
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87303(a) Maintenance and Operation“The facility shall be clean, safe, sanitary and in good repair at all times.
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Facility replaced flooring and worked with Residents to maintain a clean and sanitary enviornment. POA Cleared at time of vist
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Based on observation and interviews, LPA observed excessive clutter, cobwebs, food debris, stained flooring, and damaged flooring in resident bedrooms and bathrooms. .This posed a potential health and safety risk to 3 out 395 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: 05/28/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 2 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
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: DATE:
05/28/2026
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:TIME COMPLETED:
04:25 PM
ALLEGATION(S):
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Staff are verbally abusive to the residents
Staff did not provide healthful accommodations for the residents
Staff did not follow proper food handling techniques
Staff did not properly maintain the facility grounds
Staff lock the residents in their bedrooms
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Rodgers March 5, 2026 conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to adminstrator.

.On March 5, 2026, Community Care Licensing Division (CCLD) received a complaint alleging staff are verbally abusive to residents, staff did not provide healthful accommodations for residents, staff did not follow proper food handling techniques, staff did not properly maintain the facility grounds, and staff lock residents in their bedrooms.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, residents, outside sources, and LPA observations
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
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-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: 05/28/2026
NARRATIVE
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(continued from LIC9099a) (Room 2 of 3)

Regarding allegation: Staff are verbally abusive to the residents. LPA interviews with multiple staff, residents, and family members revealed no evidence to corroborate the statements made by the reporting party. Staff interview revealed no staff had witnessed or participated in verbally abusive conduct. Resident interview revealed no concerns regarding staff speaking disrespectfully or aggressively. Outside source interview revealed no knowledge of verbal abuse occurring. .LPA observations revealed staff interacting with residents in a professional manner.

Regarding Allegation: Staff did not provide healthful accommodations for the residents. More specifically facility staff leave resident bowel and urine messes in hallways for days and do not provide cleaning supplies to staff. LPA interviews with housekeeping staff, caregivers, and management revealed that approved cleaning products and protective equipment are available on each floor and accessible to staff at all times, and no evidence was found to support improper cleaning practices when responding to resident toileting incidents. Staff interview revealed facility approved cleaning supplies are stocked and available 24 hours a day. Resident interview revealed no concerns about environmental cleanliness .LPA observations revealed common areas and hallways to be clean and orderly.

Regarding Allegation: Staff did not follow proper food handling techniques. More specifically kitchen staff do not follow proper food handling protocols. LPA interviews with multiple staff members, including kitchen staff and caregivers, as well as interviews with residents and family members, did not reveal any evidence to support the allegation. Staff interview revealed food handling procedures are followed consistently. Resident interview revealed no concerns related to food preparation or sanitation. LPA observations revealed kitchen areas clean and properly maintained.
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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: 05/28/2026
NARRATIVE
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Continued from LIC9099A-C) Page 3 of 3


Allegation: Staff did not properly maintain the facility grounds. More specifically: LPA interviewed maintenance staff and caregivers and reviewed observations from previous visits, which showed that resident scooters and wheelchairs regularly cause wall damage that maintenance consistently repairs, and LPA did not observe any outstanding spills or staining on floors or walls during the investigation.Staff interview revealed maintenance completes repairs as needed. Resident interview revealed no concerns regarding the condition of facility grounds.Outside source interview revealed no maintenance related issues reported. Records review revealed maintenance logs documenting ongoing repairs and services LPA observations revealed no outstanding or unaddressed maintenance hazards.

Allegation: Staff lock residents in their bedrooms More specifically staff are not allowed keys to enter residents rooms. LPA observed key storage accessible to med tech staff, and staff interviews confirmed that residents may lock their doors by choice; LPA interviewed a random selection of residents with locked doors and confirmed their personal rights were not being violated, as staff knock before entering and use facility keys appropriately to ensure access. Staff interview revealed residents are permitted to lock their rooms for privacy. Resident interview revealed no reports of being prevented from exiting rooms. Outside source interview revealed no concerns relating to locked rooms. LPA observations revealed residents freely moving about the facility without restriction.

Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred; therefore, the allegations are UNSUBSTANTIATED.

An exit interview was conducted with Administrator Neale, 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 Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 05/28/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5