374604060-4-15-2022-08-AS-IESA-CDY82W-20220429220838

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604060
Report Date: 04/12/2022
Date Signed: 04/15/2022 10:36:53 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/03/2022 and conducted by Evaluator Dang Nguyen

COMPLAINT CONTROL NUMBER: 08-AS-20220103134632

FACILITY NAME:	GROSSMONT GARDENS		FACILITY NUMBER:	374604060
ADMINISTRATOR:	KAITLIN RUDOLPH		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	425	CENSUS: 179	DATE:	04/12/2022
		UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Associate Executive Director Lane Hermosillo		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Licensee did not give resident’s medication list to emergency medical personnel.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced visit to deliver a finding regarding the above prior complaint allegation. LPA was welcomed by and identified himself to receptionist Rosalinda Aqunio. LPA then met with and discussed the purpose of the visit with Associate Executive Director Lane Hermosillo.

On December 28, 2021, Resident #1 (R1) was sent to the emergency room (ER) via 911 and diagnosed with a syncopal episode (also known as “fainting”). The complainant alleged that during the send-out process, Licensee did not provide R1’s medication list to first responders/emergency medical personnel. The Department’s investigation consisted of an unannounced tour of the facility and interview of R1, relevant staff, and outside sources. Pertinent facility care records, ambulance records, and hospital records were also reviewed.

[CONTINUED ON LIC 9099-C, 1 of 2]

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

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 3

Control Number 08-AS-20220103134632

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 9099]

According to ambulance records, R1 said they were trying to move a box on the floor, fell backwards, landed on their bottom, and then got themselves back up to their feet. As corroborated by staff interviews, R1 then called out for help. Staff #1 (S1) heard them and went to R1’s bedroom, where they observed R1 standing but also looking weak, pale, and about to collapse. S1 used their own body to prop R1 up and prevent them from falling. Staff #2 (S2) and Staff #3 (S3) arrived shortly after, helping to transfer R1 to a seated position in a wheelchair. R1 appeared short of breath and told staff they were having difficulty breathing. 911 was called. S1 and S2 also called nurse Staff #4 (S4), who was in another building of the facility’s campus. S4 concurred via radio that 911 was required for R1.

Per interview of S4: they instructed S1 and S2 to photocopy R1’s emergency contact sheet, medication list, and Physician Orders for Life Sustaining Treatment form (hereafter referred to collectively as “911 paperwork”), in anticipation of the arrival of first responders. S4 also themselves made copies of these same documents, before traveling to the building where R1 was located. By the time S4 arrived at R1’s bedroom, emergency medical personnel were already onsite with R1. S4 tried to hand their copies of the R1’s 911 paperwork to the emergency medical personnel, but those same personnel told S4 that they had already received the same copies from S1 or S2.

Per interview of S1: they heard S4 instruct S2 over the radio to make copies of R1’s 911 paperwork and give to emergency medical personnel. Per interview of S2: they witnessed emergency medical personnel holding R1’s 911 paperwork before departing the facility with R1. Nurse Staff #5 (S5) was not hands-on with R1, but they were present on the facility campus during the incident, interviewed S1, and then notified R1’s responsible party about the incident. S5 had a subsequent phone call with staff at the hospital, who confirmed they received the 911 paperwork which the facility provided on R1.

[CONTINUED ON LIC 9099-C, 2 of 2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220103134632

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 04/12/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

[CONTINUED FROM LIC 9099-C, 1 of 2]

Hospital records also suggested that licensee sent R1’s medication list with them to the ER, as evidenced by: a) Around four hours after R1 went to the ER, Hospital Staff #1 (H1), a physician, wrote, “Available Med List Reviewed”; b) Hospital Staff #2 (H2), a nurse, transcribed a digitized internal medication list for R1. For multiple medications, H2 listed the “Information Source” as “Paper Chart/Abstracting”; and c) On December 29, 2021, H2 documented an incoming phone call from R1’s primary physician, who was requesting a specific medication for R1. H2 wrote, “Med listed on [patient’s] paper chart from Grossmont Gardens.”

Based on records and interviews, a preponderance of evidence does not exist to support the allegation that Licensee did not provide R1’s medication list to emergency medical personnel. The allegation is therefore unsubstantiated. An exit interview was conducted with Hermosillo, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided via E-mail.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang Nguyen	TELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3