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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604675
Report Date: 11/06/2024
Date Signed: 11/06/2024 03:55:28 PM

Document Has Been Signed on 11/06/2024 03:55 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 LIVINGFACILITY NUMBER:
374604675
ADMINISTRATOR/
DIRECTOR:		JONES, REGINALDFACILITY TYPE:
740
ADDRESS:5480 MARENGO AVETELEPHONE:
(619) 463-0281
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY: 425CENSUS: 379DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Executive Director, Reginald JonesTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Incident visit. LPA met with Executive Director, Reginald Jones and discussed the purpose of the visit.

The facility self reported an incident involving Resident #1 (R1). The report indicated R1 was agitated and attempting to elope from the community out of another resident's room. R1 was unsuccessful and redirected back to the hallway. R1 wore a wander guard, which alerted staff of the attempted elopement. However, staff were unable to reset it after it alerted due to R1's agitation, aggression, and refusal. The caregiver assisting R1, left R1 to assist another resident. Upon staff's return at approximately 5:30pm, R1 was not in their room or the designated floor where they reside. R1 resides in the facility's secured memory care unit with a coded elevator. R1 was able to leave the facility by sneaking pass the elevator while it was actively closing and putting their hand through to stop it. Staff searched for R1, contacted local law enforcement, and notified R1's responsible party. Local law enforcement found R1 and returned R1 to the facility at approximately 8:00pm, no injuries were sustained. ED also stated R1's responsible party wanted R1 to remain at the facility. However, another facility would be suitable. R1's responsible party agreed to transfer R1 to a higher level of care facility. R1 has a one on one companion when they are not at their program until transferred to the new secured facility. The Executive Director (ED) explained R1 moved into the facility on 10/29/24, had medication changes and and eloped on 10/30/24. The ED stated R1's responsible party indicated the change in medication could have been the cause for R1's aggression and anxiety. According to the ED R1 moved out of the facility on 11/01/24. Due to the facility's knowledge of R1 wanting to elope and not ensuring R1's safety, a deficiency was issued.

Based on interviews and record review, a deficiency is being issued on the attached LIC 809D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Reginald Jones whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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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Document Has Been Signed on 11/06/2024 03:55 PM - It Cannot Be Edited


Created By: Natasha Persaud On 11/06/2024 at 09:33 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: GROSSMONT GARDENS SENIOR LIVING
FACILITY NUMBER: 374604675

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/04/2024
Section Cited
CCR
87464(f)(1)

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Basic Services. Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).services necessary to meet resident needs. This requirement is not met as evidenced by:
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Executive Director stated staff will attend elopement training and submit proof of training by POC due date. In addition, ED stated there is already signage present regarding not letting residents out without notifying staff. ED stated he will add more signage to ensure resident's safety.
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Based on interviews and record review, the licensee did not ensure observation of the resident, once the resident attempted the first elopement 1 out of 379 [R1] residents, which posed a potential health and safety risk to residents 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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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