374604675-3-14-2025-08-AS-RCLK-DG92YC-20250430174832

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 03/13/2025
Date Signed: 03/14/2025 08:11:57 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
02/18/2025 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20250218121152

FACILITY NAME:	GROSSMONT GARDENS SENIOR LIVING		FACILITY NUMBER:	374604675
ADMINISTRATOR:	JONES, REGINALD		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	425	CENSUS: 369	DATE:	03/13/2025
		UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	Health Service Director, Stephanie Scudder		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility did not follow infection control guidelines

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced visit to conclude a complaint investigation. LPA identified herself and discussed the allegations mentioned above with Health Service Director, Stephanie Scudder and Executive Director, Reginald Jones.

During the investigation, LPA briefly toured the facility, requested records, interviewed staff, residents, and outside sources. It was alleged facility did not follow infection control guidelines. On 02/11/25, the facility had a Norovirus outbreak with fourteen (14) cases. The facility continued to have an outbreak with positive cases thru 02/16/25. During the duration of the outbreak the facility did not follow infection control guidelines. Facility activities and dining continued amongst residents. A review of facility correspondences indicated the facility notified San Diego Epidemiology on 02/14/25, which was three (3) days after the outbreak. Continued on an LIC 9099C.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250218121152

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: 03/13/2025

NARRATIVE

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San Diego Epidemiology provided guidance to include the following: request symptomatic residents remain in their rooms until symptom-free for at least 48 hours; if possible, provide in-room meal service and restrict ill residents from participating in group activities; temporarily discontinue or limit group activities; and disinfect common areas and high-touch surfaces with an EPA-registered cleaning product effective against Norovirus. The facility had Sani-Cloth Germicidal Disposable Wipes, which can be used to disinfect Norovirus, but only used for hard surfaces.

Resident interviews confirmed not having knowledge of the outbreak. Some residents that were infected stated they continued to eat meals in the dining room and stayed away from their friends by choice, not to infect others. Infected residents revealed they were not provided guidance by staff to self-isolate. Therefore, they continued to interact with other residents. Resident interviews also confirmed staff entered the resident’s room during the infected time period without PPE. In addition, residents stated signs were not posted on their doors to reflect contagious outbreak. A resident not infected revealed they were not made aware by staff the facility had an outbreak. Per the Executive Director, emails were sent to the resident and responsible parties. However, some residents do not have access to emails. A review of the facility records indicated the email was sent to the residents/responsible parties on 02/17/25, which was after the infected period. The email stated “We will continue to provide you with updates as they become available. Please know that we are strictly adhering to all directions from the local and state health department.” The facility did not follow the recommendation of the health department to limit activities and dining. Outside source interviews revealed there were no follow up emails sent to families. Outside source interviews confirmed they were not notified about the outbreak until days later after the outbreak. Outside interviews also stated there were no signs posted in the facility warning people of the outbreak.

One resident went to the hospital and upon return the following the day, their room was not disinfected. The room was observed with liquid feces on the floor, carpet, and bedding. Staff explained they have disinfectant wipes that could have cleaned the feces off the floor. However, available products to staff did not include a bleach-based solution to disinfect the room, at the time of the resident’s return. Staff explained they were not aware the resident was returning to the facility from the hospital. LPA explained all rooms should be disinfected on a regular basis when there is an infectious outbreak. Staff stated an order must be placed to clean the carpets, as that is not handled by caregivers or housekeeping. The facility shall be prepared to ensure infection control guidelines are followed, regardless of the time of day or resident’s absence from the community. Continued on an LIC 9099C.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250218121152

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: 03/13/2025

NARRATIVE

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The resident’s room was disinfected by the resident’s family member using a bleach-based solution. The facility should have mitigated the infection by ensuring the infected resident rooms were disinfected and activities and dining should have been limited. The infected residents were walking around the facility and interacting with the other residents. The Executive Director (ED) explained isolation of residents can be difficult on residents when they are not able to interact/socialize with one another. LPA explained it was more important to stop the spread of the virus, which is harmful to residents. The facility has a Lead Infection Preventionist assigned to the facility. However, they were not aware of the details of the outbreak and/or involved with the mitigation. According to the ED there are two (2) assigned Leads to the facility, which was not documented. In addition, the Lead documented on their Infection Control Plan should have been involved to assist with mitigation.

Based on interviews which were conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Health Service Director, Stephanie Scudder whose signature below confirms receipt of these rights.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20250218121152

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: 03/13/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 04/10/2025 Section Cited CCR 87470(a)	1 2 3 4 5 6 7	Infection Control Requirements A licensee shall ensure that infection control practices are maintained as follows: This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Eexecutive Director agreed to have staff trained on infection control and update their infection control plan to reflect the Lead Preventionist.
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure infection control guidelines were followed for 26 out of 374 (R1-R26) residents, which posed a health and safety risk to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025

LIC9099 (FAS) - (06/04)

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