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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604060
Report Date: 04/11/2024
Date Signed: 04/11/2024 12:30:01 PM


Document Has Been Signed on 04/11/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GROSSMONT GARDENSFACILITY NUMBER:
374604060
ADMINISTRATOR:LANE HERMOSILLOFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:0CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:N/A, Report Mailed to LicenseeTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted this Case Management process to cite a deficiency which was identified during a separate Complaint investigation. Since the facility closed on 05/04/2023 due to a change in ownership, the deficiency finding was delivered to Licensee via USPS certified mail.

Resident #1 (R1) moved into the facility on 10/18/2021, under the concurrent care of an outside hospice agency. Facility and hospice care records showed R1 had total loss of use of both legs and fully relied on facility staff for mobility and turning/repositioning in bed. In assessment notes and nursing notes, Licensee’s own staff documented R1 on 10/18/2021 had preexisting redness on their coccyx (i.e., tailbone) area, but no other skin breakdown. Per hospice agency notes, at time of move-in there was redness on R1’s coccyx which was “dry.” However, R1’s coccyx skin was closed and there was no identification of redness and/or skin breakdown to any other area of R1’s body.


Dated, handwritten progress notes from the facility’s own nurses showed that on 10/21/2021: R1 had new pressure injuries to their left hip and right upper back (in addition to their existing coccyx injury). Facility staff received and logged orders from R1’s doctor for dressing changes and instructions to turn and reposition R1’s body every two hours, and to “float” R1 heels so that they don’t touch the mattress when R1 is laying.



[CONTINUED ON LIC 809-C]
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GROSSMONT GARDENS
FACILITY NUMBER: 374604060
VISIT DATE: 04/11/2024
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[CONTINUED FROM LIC 809]

According to hospice agency electronic progress notes, their nurse visited on 10/23/2021 and found R1 flat on their back in bed (not rotated, as was instructed by R1’s physician). The pillows provided to facility staff to prop up and reposition R1 were instead on the floor of their bedroom. Facility records, hospice records, and interviews of facility managers and outside sources further showed: Licensee held a 10/27/2021 care conference with R1’s hospice agency staff and R1’s responsible person to announce that routinely turning/repositioning R1 in bed and floating their heels was not something that facility staff did for R1 since they moved in, and not something facility staff would do for R1 going forward. Later the same day, R1’s hospice agency and responsible person had R1 sent to a hospital emergency room (ER) for treatment of multiple pressure injuries.

According to hospice notes, on 10/27/2021, R1’s coccyx pressure injury had expanded to 2 cm long by 2 cm wide, with “purulent” (i.e., containing pus) drainage. The pressure injury on R1’s right upper back was now 2.5 cm long by 2 cm wide, with “purulent” drainage. R1 also now had an “unstageable” ulcer on their left hip that was 1 cm long by 2 cm wide with no drainage, plus a “Stage 1” (i.e., redness, closed skin) pressure injury on their left heel which was 3 cm by 3 cm, and “blisters” on their right heel which were 3 cm by 3 cm. According to ER hospital records, R1 came to the ER on 10/27/2021 because they had a “wound on coccyx and staff at the facility are unable to care for it.” Hospital staff assessed R1’s “sacral / coccygeal” pressure injury as 2.5 cm long by 3 cm wide, “unstageable,” and infected (but not septic), for which R1 received intravenous antibiotics. They also assessed R1’s left and right heels as both “Stage 1.”


Based on interviews and records, a preponderance of evidence exists to show that Licensee did not ensure that R1’s skin condition (which was an allowable health condition at their time of their move-in) was cared for in accordance with their physician’s orders and that their medical needs were met. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the LIC 809-D) page. The Department determined that the violation resulted in injury to a resident in care. An immediate civil penalty of $500 was already assessed on a separate Complaint Visit report for this incident involving R1.

Since the facility had closed and ceased operations as of the date of deficiency issuance, no Plan of Correction was formed with the Licensee. A copy of this report, the LIC 809-D, and the Licensee/Appeal Rights (LIC9058 03/22) were provided to Licensee via USPS certified mail.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/11/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GROSSMONT GARDENS

FACILITY NUMBER: 374604060

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 04/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/11/2024
Section Cited
CCR
87633(e)

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87633 General Requirements for Allowable Health Conditions: “(e)…the licensee shall ensure that the resident is cared for in accordance with the physician’s orders and that the resident’s medical needs are met.” This requirement was not met, as evidenced by:
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As of the date of deficiency issuance, R1 had already passed away and the facility had closed and ceased operations. Therefore, no Plan of Correction was formed with the Licensee.
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Based on records and interviews, for 1 of 200 residents (R1), Licensee did not ensure that their allowable health condition for was care for in accordance with their physician’s orders and that their medical needs were met. This posed an immediate health 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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