374604684-12-8-2025-08-AS-SJAB-DP8V32-20251210150359

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374604684
Report Date: 11/17/2025
Date Signed: 12/08/2025 12:56:00 PM

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 Amy Domingo

COMPLAINT CONTROL NUMBER: 08-AS-20250218154245

FACILITY NAME:	GROSSMONT GARDENS MEMORY CARE		FACILITY NUMBER:	374604684
ADMINISTRATOR:	SUZETTE JOHNSON		FACILITY TYPE:	740
ADDRESS:	4960 MILLS STREET		TELEPHONE:	(619) 644-1100
CITY:	LA MESA	STATE: CA	ZIP CODE:	91942
CAPACITY:	64	CENSUS: 62	DATE:	11/17/2025
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Natalie Carlborg Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not ensure resident had enough liquids, resulting in dehydration

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Amy Domingo conducted an unannounced visit to deliver findings regarding the above complaint allegation. LPA introduced herself and disclosed the purpose of the visit to Executive Director Natalie Carlborg.

CCLD’s investigation involved unannounced facility tour/welfare checks and review of facility care and medical records. The Department also interviewed relevant staff, clients, and outside sources.

On 2/18/25, it was alleged that facility staff did not ensure the resident had enough fluids, resulting in dehydration.

Staff 1 (S1) was interviewed and revealed that hydration is offered during meals and snacks and medication pass, but they do not track how much a resident drinks unless there is a specific order.

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

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 4

Control Number 08-AS-20250218154245

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: 11/17/2025

NARRATIVE

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(Continued from LIC9099 2 of 3)

Staff 2 (S2) was interviewed and stated that the R1 did not notice any changes with R1. S2 stated R1 was at baseline.

Staff 3 (S3) was interviewed and confirmed that there was no hydration monitoring in place for R1, but hydration is offered during activities, medication pass and at all meals. S3 stated that they rely on caregivers to report concerns to the medication technologist, who report any changes to the medical physician.

Interviews with three (3) residents were conducted, and they did not express any concerns regarding hydration.

LPA observed residents in the dining room during activities, meals, and snacks, and fluids were being offered to residents. Residents who needed assistance were being assisted with drinking fluids.

Outside Source 1 (OS1) was interviewed and stated that R1 had experienced multiple episodes of unresponsiveness, vomiting, and shallow breathing while at the facility. OS1 raised concerns about R1’s hydration status, and requested staff to ensure R1 was receiving adequate fluids. OS1 communicated to the facility that R1 had been hospitalized due to dehydration.

Outside Source 3 (OS3) was interviewed and stated that the facility did do their due diligence with sending R1 to the hospital when there were episodes of unresponsiveness, vomiting, and shallow breathing while at the facility.

A review of facility records and incident documentation for R1 revealed that the facility did not document if the resident was refusing hydration therefore there was no means of tracking if the resident received adequate hydration. According to a progress note dated 01/21/2025, OS1 reported that R1 had been hospitalized and diagnosed with dehydration.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 08-AS-20250218154245

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: 11/17/2025

NARRATIVE

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(Continued from LIC 9099C 3 of 3)

The Department has investigated a complaint with the above allegation. The Department has found that there is a preponderance of evidence to prove that the alleged violation did occur; therefore, the allegation is substantiated. A deficiency is cited per California Code of Regulations, Title 22 (refer to the attached LIC 9099-D). A Plan of Correction was jointly developed with the licensee. An exit interview was conducted with the 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: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 08-AS-20250218154245

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/17/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/17/2025 Section Cited CCR 87465(a)(1)	1 2 3 4 5 6 7	Type B CCR 87465(a)(1)A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical …The licensee shall arrange, or assist in arranging, for medical…appropriate to the conditions and needs of residents.	1 2 3 4 5 6 7	Administrator agrees to conduct a incidental medical and dental needs and service care plan training for and Resident Care Coordinator and the Assessment Nurse by 12/17/2025.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on records review and interviews, facility personnel did not provide basic care services to (R1) one out of 62 residents. This posed a potiential health risk to a resident 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.

SUPERVISORS NAME: Simon Jacob
LICENSING EVALUATOR NAME: Amy Domingo
LICENSING EVALUATOR SIGNATURE:	DATE: 11/17/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2025

LIC9099 (FAS) - (06/04)

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