374604684-10-9-2025-08-AS-SJAB-DNZTYX-20251203140924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 09/30/2025
Date Signed: 10/09/2025 03:13:54 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
07/05/2023 and conducted by Evaluator Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20230705125821

FACILITY NAME:	GROSSMONT GARDENS MEMORY CARE		FACILITY NUMBER:	374604684
ADMINISTRATOR:	AYERSMAN, JENNIE		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	64	CENSUS: 62	DATE:	09/30/2025
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Natalie Carlborg, Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Resident death due to staff neglect
Improper transfer resulting in injury
Medication not given as prescribed
Facility retained resident against their will
Staff does not have medication training
Staff drank alcohol while on duty
Staff used drugs while on duty

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver the findings in the above-mentioned complaint allegations. LPA Domingo identified herself and discussed the purpose of the visit with Executive Director, Natalie Carlborg.

During the investigation, LPA Domingo collected pertinent resident records as well as facility documentation and conducted interviews with staff, residents, and outside sources.

On 07/05/2023, the department received a complaint alleging a resident's death due to staff neglect. LPA reviewed Resident 3’s (R3's) Appraisal/Needs and Services Plan, and the physician’s report indicated multiple chronic health conditions. Daily care logs and medication administration records showed consistent documentation of care provided, including vital signs monitoring, medication compliance, and physician follow-up. The Unusual Incident/Injury Report and Death Report were submitted to the Department within the required timeframe.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

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 6

Control Number 08-AS-20230705125821

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 MEMORY CARE	FACILITY NUMBER: 374604684
	VISIT DATE: 09/30/2025

NARRATIVE

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(LIC9099C 2 of 6)
Interview with Staff 1 (S1) confirmed that the resident was receiving appropriate care and supervision in accordance with their care plan. Staff responded immediately when the resident was found unresponsive and contacted emergency services. Interview with Staff 2 (S2) described the events leading up to the incident and confirmed that the resident had not expressed any new complaints or symptoms prior to the event. Interview with Staff 3 (S3) verified that all medications were administered as prescribed and that the resident’s condition was stable during the days leading up to the incident. Interview with Outside source 1 (OS1) stated they were satisfied with the care provided and had no concerns about staff attentiveness or neglect. Confirmed that the resident’s death was consistent with their known medical conditions and not indicative of neglect.

LPA observed the facility appeared clean, organized, and appropriately staffed at the time of the visit. Staff were observed following care protocols and referencing resident care plans during shift transitions.

On 07/05/2023, the department received a complaint alleging that medication was not given as prescribed.
LPA reviewed R2’s physician orders dated included prescriptions for R2's medical needs. The Medication Administration Records (MARs) for the past 30 days showed consistent documentation of medication administration with no missed doses or discrepancies. Centrally stored medication logs were complete and matched the medications on hand.

Interview with S1 confirmed that all staff responsible for medication administration are trained and certified. Stated that MARs are reviewed weekly for accuracy. Interview with S2 demonstrated knowledge of Resident 1’s medication regimen and described the facility’s double-check system for medication passes. Interview with S3 reported no issues with medication refusals or errors for R2.

Outside Source 1 (OS1) stated they receive their medications daily and have not experienced any missed doses. Responsible Party: Reported no concerns regarding medication administration and confirmed that the resident’s health has been stable.

LPA observed medications were observed to be properly labeled, stored in a locked cabinet, and organized by resident. Staff were observed following proper procedures during a medication pass, including verifying the resident, medication, dosage, and time.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 08-AS-20230705125821

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 MEMORY CARE	FACILITY NUMBER: 374604684
	VISIT DATE: 09/30/2025

NARRATIVE

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LIC9099C 3 of 6
On 07/05/2023, the department received a complaint alleging improper transfer resulting in injury. Record review R5’s Appraisal/Needs and Services Plan indicated the need for two-person assist with transfers and use of a gait belt. There was no Unusual Incident/Injury Report due to no fall was reported. The report indicated no fall occurred and that the transfer was completed per protocol.

Interview with S1 confirmed that staff involved in the transfer were trained and certified in proper transfer techniques. Interview with S2 stated they use a gait belt and followed the two person assist protocol. They denied any deviation from the resident’s care plan. Interview with S3 reported that the resident was assessed immediately after the complaint of pain and that the responsible party and physician were notified. Interview with OS2 reported being notified promptly and expressed no concerns about the staff’s handling of the situation.

LPA observed staff were observed assisting another resident using proper body mechanics and transfer techniques, including the use of gait belts and verbal cues. Transfer equipment (e.g., gait belts, walkers) was available and in good condition.

On 07/05/2023, the department received a complaint alleging the facility retained a resident against their will. Review of R5’s Admission Agreement and Needs and Services Plan did not include any legal restrictions or conservatorship limiting their ability to leave the facility. No documentation was found indicating that the resident was placed on any form of hold or restriction. The facility’s Resident Rights Policy clearly states that residents may leave the facility voluntarily unless medically or legally restricted.

Interview with S1 stated that R5 has not expressed a desire to leave the facility. Interview with S2 confirmed that the resident was not physically or verbally restrained and that staff only encouraged the resident to wait until a responsible party could be contacted. Interview with S3 reported that the resident was calm and cooperative and that no intervention was required.

OS2 stated there has not been any signs or symptoms of R5 expressing they are being kept against their will. OS2 confirmed they are always contacted by the facility when there are changes in R5's behavior and appreciated that staff ensured the resident’s safety while respecting their rights.

LPA observed Facility posted Resident Rights in a visible location, including the right to leave the facility voluntarily. No signs of restraint, isolation, or coercion were observed during the visit.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 08-AS-20230705125821

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 MEMORY CARE	FACILITY NUMBER: 374604684
	VISIT DATE: 09/30/2025

NARRATIVE

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LIC9099C 4 of 6

On 07/05/2023, the department received a complaint alleging staff does not have medication training.
Records Reviewed of staff training files reviewed for five staff members responsible for medication assistance included: Certificates of completion for initial 6-hour medication training. Documentation of 8 hours of annual medication training. Competency assessments signed by a qualified professional
Training logs were current and matched the staff schedules for medication administration.

S1 confirmed that all staff who assist with medications have completed the required training and are monitored for ongoing compliance. S2 provided a copy of their training certificate and described the procedures followed during medication passes. S3 confirmed they do not assist with medications and are aware of the facility’s policy regarding medication handling.

LPA observed staff administering medications using proper procedures, including: Verifying resident identity, checking medication labels and MARs. Documenting administration immediately after delivery. Medications were stored securely and labeled appropriately.

On 07/05/2023, the department received a complaint alleging that staff drank alcohol while on duty.
Records Reviewed of staff personnel files included signed Code of Conduct and Drug-Free Workplace Policy agreements. There were no disciplinary actions, incident reports, or documentation indicated staff impairment or alcohol use while on duty. The Facility policy strictly prohibits the use of alcohol or controlled substances during work hours.

S1 denied any knowledge of staff consuming alcohol on duty and confirmed that all staff are trained on the facility’s substance use policy. S2 denied the allegation and stated that alcohol is not permitted on the premises. Both appeared alert and professional during the visit.
S3 confirmed that staff are subject to disciplinary action and possible termination if found under the influence while working.

R5 and R5 reported no concerns about staff behavior or professionalism. Both stated that staff are attentive and respectful. OS1 expressed satisfaction with the care provided and stated they had never observed or been informed of any inappropriate staff conduct.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 08-AS-20230705125821

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 MEMORY CARE	FACILITY NUMBER: 374604684
	VISIT DATE: 09/30/2025

NARRATIVE

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LIC9099C 5 of 6

During unannounced visits, staff were observed performing duties appropriately, with no signs of impairment. No alcohol or related paraphernalia was observed in staff areas or common spaces.

On 07/05/2023, the department received a complaint alleging that staff used drugs while on duty. Records Reviewed of staff personnel files included signed Code of Conduct and Drug-Free Workplace Policy agreements. No disciplinary actions, incident reports, or documentation indicated staff impairment or alcohol use while on duty. Facility policy strictly prohibits the use of alcohol or controlled substances during work hours.

S1 denied any knowledge of staff consuming drugs on duty and confirmed that all staff are trained on the facility’s substance use policy. S2 denied the allegation and stated that alcohol is not permitted on the premises. Both appeared alert and professional during the visit. S3 confirmed that staff are subject to disciplinary action and possible termination if found under the influence while working.

R5 and R6: Reported no concerns about staff behavior or professionalism. Both stated that staff are attentive and respectful.

OS2 expressed satisfaction with the care provided and stated they had never observed or been informed of any inappropriate staff conduct.

During unannounced visits, staff were observed performing duties appropriately, with no signs of impairment. No drug or related paraphernalia was observed in staff areas or common spaces.

On 07/05/2023, the department received a complaint alleging that staff did not provide residents with medical treatment. Resident records reviewed for five randomly selected residents showed documentation of timely physician visits, medication administration, and follow-up care. Incident reports and progress notes reflected appropriate staff response to changes in condition, including contacting physicians and responsible parties. No documentation indicated delays or refusals to provide medical treatment.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

Page: 5 of 6

Control Number 08-AS-20230705125821

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 MEMORY CARE	FACILITY NUMBER: 374604684
	VISIT DATE: 09/30/2025

NARRATIVE

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LIC9099C 6 of 6

On 07/05/2023, the department received a complaint alleging that staff did not provide residents with medical treatment. Resident records reviewed for five randomly selected residents showed documentation of timely physician visits, medication administration, and follow-up care. Incident reports and progress notes reflected appropriate staff response to changes in condition, including contacting physicians and responsible parties. No documentation indicated delays or refusals to provide medical treatment.

S1 confirmed that the facility has protocols in place for responding to medical needs, including contacting physicians, hospice, or emergency services as appropriate. S2 described procedures for monitoring resident health and initiating medical intervention when needed. S3 reported that staff are trained to observe and report any signs of illness or injury immediately.

R5 and R6 reported satisfaction with the care provided and stated that staff respond promptly when they feel unwell.

OS2 and OS3 confirmed that the facility communicates effectively and has arranged medical care when needed.

Residents appeared well-groomed, alert, and comfortable during the visit. Staff were observed checking on residents and documenting care in real time. There were no signs of untreated illness or injury were observed.

The Department has investigated a complaint with the above allegations. The Department has found that although the allegations may have occurred or be valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur; therefore, the allegations are unsubstantiated. An exit interview was conducted with Natalie Carlborg, Executive Director to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/30/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2025

LIC9099 (FAS) - (06/04)

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