374604675-12-15-2025-08-AS-SJAB-DPLVE7-20251222152151

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604675
Report Date: 12/15/2025
Date Signed: 12/15/2025 04:24:09 PM

Unsubstantiated

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
05/28/2025 and conducted by Evaluator Amy Rodgers

COMPLAINT CONTROL NUMBER: 08-AS-20250528101453

FACILITY NAME:	GROSSMONT GARDENS SENIOR LIVING		FACILITY NUMBER:	374604675
ADMINISTRATOR:	TORINO, LYNN		FACILITY TYPE:	740
ADDRESS:	5480 MARENGO AVE		TELEPHONE:	(619) 463-0281
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	425	CENSUS: 380	DATE:	12/15/2025
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Executive Director Chris Neale		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff did not keep facility clean from spread of infectious disease

INVESTIGATION FINDINGS:

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LPA Rodgers conducted an unannounced visit to the facility to further invisigate and deliver findings regarding the above complaint allegations. The visit was conducted via email with Executive Director Chris Neale. The Department’s investigation included unannounced facility visits, interviews with facility staff, residents, and outside sources, as well as a review of facility records.

On 5/28/2025, it was alleged that staff did not keep facility clean from spread of infectious diseases. More spefically, staff on the 1st and 4th floors of the East Building were not properly disinfecting the facility during a scabies outbreak, resulting in reinfection among residents and staff.

Department interviews with staff revealed that all affected residents were aware they had contracted scabies, and that all dermatological reactions were prophylactic. Residents were receiving appropriate treatment, including Ivermectin and topical creams..(continued on LIC9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

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-20250528101453

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: 12/15/2025

NARRATIVE

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(Continued from LIC 9099)
Staff reported that personal protective equipment (PPE) was available and used during care, and that laundry for infected individuals was separated and handled according to infection control protocols. Housekeeping staff cleaned resident rooms and common areas daily, using hospital-grade disinfectants on high-touch surfaces. However, staff interview responses were inconsistent. While several staff members stated that infection control protocols were followed, others expressed frustration after contracting scabies, attributing their exposure to lapses in infection control practices. Some staff reported concerns included delays in receiving PPE, inconsistent disinfection of shared equipment, and lack of enforcement of resident isolation. Department interviews with Executive Director Jones confirmed that treatment was provided and that PPE was made available to all staff.

The Department's interviews with residents consistently reported that staff had been responsive and helpful during the outbreak. Residents confirmed that information about infection control had been posted on their doors and throughout the facility. They stated that staff assisted with medication application, and none reported experiencing severe symptoms or requiring hospitalization. Residents also noted that the facility was kept clean and that staff were attentive to their needs.

The department also reviewed documentation and confirmed that the facility posted signs regarding PPE use and infection control protocols as well as in-service trainings on 2/12/2025, 3/20/2025, and 3/27/2025. Email communications showed that Executive Director Jones notified residents, families, and public health authorities, including San Diego Public Health and the CDC. Incident reports and other documentation confirmed the Licensee’s efforts to manage the outbreak and support affected individuals. During many unannounced visits, LPA observed the facility to be clean and well-maintained. Housekeeping staff were seen actively cleaning and sanitizing surfaces. Infected laundry was properly bagged and labeled for isolation. Hospital-grade disinfectant wipes were available throughout the facility. No signs of unsanitary conditions were observed.

Based on interviews, and records review and department observations there is not a preponderance of evidence to prove alleged violations occurred, therefore the allegation is UNSUBSTANTIATED.

An exit interview was conducted with Executive Director via email. A copy of this report and the Licensee/Appeal Rights (LIC9058 01/16) were provided to both via E-mail.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Rodgers
LICENSING EVALUATOR SIGNATURE:	DATE: 12/15/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025

LIC9099 (FAS) - (06/04)

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