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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 06/17/2026
Date Signed: 06/19/2026 10:03:22 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
05/08/2026 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20260508093615
FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:SCOTT-KAPLIOFF, ANGELAFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:64CENSUS: 62DATE:
06/17/2026
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Natalie Carlborg, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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 Licensee did not ensure that admission agreement was signed
INVESTIGATION FINDINGS:
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***This is an Amended Document***
Licensing Program Analyst (LPA) Amy Rodgers conducted an unannounced visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to the Executive Director.

The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review.

On May 8, 2026, Community Care Licensing Division (CCLD) received a complaint alleging the licensee did not ensure that the admission agreement was signed. More Specifically, the Reporting party (RP) alleged that they signed admission documents both in person and through DocuSign as a responsible person for Resident #1 (R1); however, none of the documents were signed or dated by Grossmont Garden Memory Care (GGMC).
(Continued on lic 9099C)
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
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-20260508093615
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: 06/17/2026
NARRATIVE
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(continued from lic9099)

Department review of records reveal 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).

Department staff interview revealed that R1's responsible person signed a preliminary packet by hand as well as the DocuSign admissions agreement. Records review revealed that DocuSign Certificates of Completion showed the March 28 and March 29 packets were configured so that only the RP was designated as a signer, while facility staff were carbon-copy recipients only, preventing staff signatures. The handwritten packet contained only the RP’s signature. No GGMC signatures were present in the admission file.

Based on relevant interviews and records review, 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 9099-D). A Plan of Correction was jointly developed with the licensee.

An exit interview was conducted with the Executive Director, 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: 06/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 4
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
05/08/2026 and conducted by Evaluator Amy Rodgers
COMPLAINT CONTROL NUMBER: 08-AS-20260508093615

FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:SCOTT-KAPLIOFF, ANGELAFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:64CENSUS: DATE:
06/17/2026
UNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Natalie Carlborg, Executive DirectorTIME COMPLETED:
04:30 PM
ALLEGATION(S):
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Staff did not provide a copy of the admission agreement
INVESTIGATION FINDINGS:
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****This is an Amended Document***Licensing Program Analyst (LPA) Amy Rodger conducted an unannounced invistigate and visit to deliver findings regarding the above complaint allegations. LPA introduced themselves and disclosed the purpose of the visit to the Executive Director.
The Department’s investigation consisted of unannounced facility visits, interviews with facility staff, and records review.
On May 8, 2026, Community Care Licensing Division (CCLD) received a complaint alleging the licensee did not provide the resident’s representative with a complete copy of the admission agreement. More specifically, the RP alleged that she received only “odd-numbered pages” of the in person admission packet and did not receive a complete copy of the documents.
Department interview with Executive Directorr stated that the facility emailed the R1's responsible person a full digital copy of the complete admission documents through DocuSign. Department interview with R1's responsible person revealed she received partial paper copies but acknowledged receiving electronic DocuSign documents as well. Records review revealed the DocuSign Certificates of Completion showed the R1's responsible person received and completed the full admission packets on March 28 and March 29, 2025. Facility records matched the complete DocuSign packets.
Based on interviews and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegation is UNSUBSTANTIATED.
An exit interview was conducted with the Executive Director, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026
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 4
Control Number 08-AS-20260508093615
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: 06/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/17/2026
Section Cited
CCR
87507(c)
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87507(c)Admission agreements shall be signed and dated.., and the licensee or the licensee’s designated representative no later than seven days following admission.

This requirement was not met in evidence as:
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Licensee agrees to retrain all administrative staff on Title 22 admission agreement requirements, including documentation procedures. Proof of staff training, including sign-in sheets and the training materials used, shall be submitted to LPA by 6/17/2026
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Based on record review, the licensee did not sign and date the admission agreement as required by Title 22, Section 87507(c), for 1 of 1 persons in care (R1), which poses a potential health and safety risk.
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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: 06/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 4