374604675-5-7-2025-08-AS-NPED-DGG2AT-20250507171400

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374604675
Report Date: 05/07/2025
Date Signed: 05/07/2025 05:14:09 PM

Document Has Been Signed on 05/07/2025 05:14 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	GROSSMONT GARDENS SENIOR LIVING		FACILITY NUMBER:	374604675
ADMINISTRATOR/ DIRECTOR:	TORINO, LYNN		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY: 425	TOTAL ENROLLED CHILDREN: 0	CENSUS: 372	DATE:	05/07/2025
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Administrator, Lynn Torino		TIME VISIT/ INSPECTION COMPLETED:	11:00 AM

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	Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Case Management - Other visit. LPA met with Administrator, Lynn Torino and discussed the purpose of the visit. The facility submitted a request for delayed egress exits in the facility's East Building on the first, and third floors, only. On 02/20/25, the fire department inspected, verified, and granted the delayed egress exits, for the requested areas. Today, LPA toured the first, second, and third floors and observed delayed egress on each floor. One of the delayed egress exits located on the third floor was not working. The Environmental Services Director stated it was inoperable and they needed to order parts. They were not aware it was inoperable, until LPA made them aware. LPA reviewed the facility's sketch requesting delayed egress. The second floor was not included on the sketch to identify delay egress will be in use. LPA spoke with the Executive Director (ED), Reginald Jones via telephone, while at the facility. The ED stated they walked each floor of the East Building with the Fire Marshal and it was confirmed the facility could use delayed egress on the first, second, and third floor. Therefore, they have been using delayed egress on all three floors. LPA confirmed with the Fire Marshal that the facility sketch was followed to grant the fire clearance for delayed egress on two of the four floors. The Fire Marshall confirmed the facility never had approval for delayed egress on the second floor. As of today, the ED requested staff cease the use of delayed egress on the second floor and understood it must be approved by the fire department before operating. LPA also observed the first floor was made a secured floor by the use of key pad located by the elevator. The key pad requires a code in order to exit the first floor by elevator. Only staff have the key code. If residents want to leave the floor they require staff to escort them and enter the code to exit. Staff explained the first floor of the East building is being made into a another memory care unit. However, the licensee did not apply for secured/locked perimeter on the first floor. Continued on an LIC 809C.

Robyn Clark	TELEPHONE: (619) 767-2312
Natasha Persaud	TELEPHONE: (619) 301-3594
	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

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

LIC809 (FAS) - (06/04)

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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 05/07/2025

NARRATIVE

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The ED was made aware and under the assumption delayed egress was the same as secured perimeter. The ED requested today that the staff disable the key pad on the first floor, until approved. Today, the ED had staff appointed to oversee the elevator, while the key pad is deactivated to ensure residents with a Major Neurocognitive Disorder are safe from elopement and harm.

The ED was made aware the delayed egress and secured perimeter require the fire department's approval. The ED was also made aware civil penalties are being assessed and will continue until corrected, by submission of applications.

deficiencies were issued along with civil penalties. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Administrator, Lynn Torino 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: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/07/2025 05:14 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
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: 05/07/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 05/08/2025 Section Cited CCR 87705(f)(2)	1 2 3 4 5 6 7	Care of Persons with Dementia. Licensees that lock exterior doors...and continuing requirements: The licensee shall ensure...fire clearance includes approval of locked exterior doors...equipment needed to unlock exterior doors or perimeter fence gates. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director, had staff disable the key pad requiring a code to exit the first floor, removing immediate threat and it will not be use until approved by the fire department. In addition, the ED stated they will submit an application to apply for secured perimeter.
	8 9 10 11 12 13 14	Based on observations, interviews and record review, the licensee did not obtain an approved fire clearance to lock the first floor by use of a key pad code to exit via elevator for 144 out of 372 residents [R1-R144] , which poses an immediate health and safety risk to residents.	8 9 10 11 12 13 14	A civil penalty was assessed.
Type A 05/08/2025 Section Cited CCR87203	1 2 3 4 5 6 7	Fire Safety. All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.	1 2 3 4 5 6 7	Executive Director, had staff disable the delayed egress on the second floor of the east building, removing immediate threat and it will not be use until approved by the fire department. In addition, the ED stated they will submit an application to apply for delayed egress on the second floor of the East
	8 9 10 11 12 13 14	Based on observations, interviews and record review, the licensee did not follow the approved fire clearance for delayed egress for 144 out of 372 residents [R1-R144] , which poses an immediate health and safety risk to residents.	8 9 10 11 12 13 14	building. A civil penalty was assessed.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Robyn Clark	TELEPHONE: (619) 767-2312
Natasha Persaud	TELEPHONE: (619) 301-3594
	DATE: 05/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/07/2025

LIC809 (FAS) - (06/04)

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