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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374604684
Report Date: 01/05/2024
Date Signed: 01/05/2024 04:59:45 PM


Document Has Been Signed on 01/05/2024 04:59 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108



FACILITY NAME:GROSSMONT GARDENS MEMORY CAREFACILITY NUMBER:
374604684
ADMINISTRATOR:SUZETTE JOHNSONFACILITY TYPE:
740
ADDRESS:4960 MILLS STREETTELEPHONE:
(619) 644-1100
CITY:LA MESASTATE: CAZIP CODE:
91942
CAPACITY:64CENSUS: 56DATE:
01/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Executive Director Suzette JohnsonTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Dang Nguyen and Juliana Barfield conducted an unannounced Case Management - Incident visit. LPAs were welcomed by, identified themselves to, and discussed the purpose of the visit with Executive Director Suzette Johnson.

Today's visit was in response to an SOC341 Report of Suspected Dependent Adult/Elder Abuse, which licensee self-submitted to the CCLD San Diego Regional Office (received on 12/27/2023), involving Staff #1 (S1) and Resident #1 (R1). [See LIC 811 Confidential Names List for a description of person identifiers used in this report].

During today’s visit, LPAs performed a facility tour. At the time of the visit, R1 was off-site and unable to be interviewed. However, a welfare check was performed on other residents in care. LPAs also reviewed pertinent care and investigative records and interviewed other relevant residents and staff.

According to R1’s latest LIC602 Physician’s Report (dated 10/23/2023), R1 was diagnosed with Dementia. Their doctor stated that while R1 was “confused/disoriented,” R1 was also able to follow instructions and able to communicate needs.

According to staff interviews: Multiple managers and caregivers noted that R1 had a tendency towards tactile stimulation, sometimes touching things or others out of curiosity. During the evening of 12/23/2023, R1 touched Resident #2’s (R2) shoulder, which bothered R2. Staff #2 (S2) said they saw S1 slap R1’s arm. S2 reported their concerns about the incident to facility management. In their written statement, S1 said they “grab[bed]” R1’s hand to redirect them away from R2. There were no injuries to either resident.


[CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: GROSSMONT GARDENS MEMORY CARE
FACILITY NUMBER: 374604684
VISIT DATE: 01/05/2024
NARRATIVE
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[CONTINUED FROM LIC 809]

Per staff interviews, personnel records, and interview of Resident #3 (R3): there was another incident occurring on 12/28/2023, involving S1 and R3. On this date, S1 was speaking on their personal cell phone inside R3’s bedroom. R3 became annoyed and asked S1 to stop. S1 did not, so R3 used their own cell phone to document S1’s actions. When S1 saw this, they physically took R3’s own cell phone away, against their will, to delete the photo which R3 took of them, before returning the phone to R3. R3 said during the scuffle over the phone, R3’s arm brushed up against a wall. R3 stated that they did not believe S1 intended to hurt them, and that S1 was going after their phone, not R3 themselves.

LPAs observed that although R3 was diagnosed with Dementia (per their latest LIC602 Physician’s Report dated 12/19/2023), R3 spoke coherently and knew the present year, the present city they were in, the name of the facility, and the name of the current US President. R3 was able to be qualified as a credible witness for this case. R3’s description of incident to CCLD was consistent with the description they earlier gave to Licensee. LPAs observed a very minor scab on R3’s left elbow, which R3 attributed to the incident with S1.

According manager interview and personnel records, Licensee’s terminated S1 employment on 01/04/2024, citing S1’s “violation of Resident’s Rights” as one of the reasons.

A preponderance of evidence exists to show that Licensee’s staff (S1), through their actions, did not uphold resident dignity and privacy. Two (2) deficiencies were cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). Plan of Corrections were jointly developed with the licensee.

An exit interview was conducted with Johnson, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 01/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/05/2024 04:59 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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108


FACILITY NAME: GROSSMONT GARDENS MEMORY CARE
FACILITY NUMBER: 374604684

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/04/2024
Section Cited
CCR
87468.1(a)(1)

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87468.1 Personal Rights of Residents in All Facilities: “(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff...”
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Per manager interview and personnel records, S1’s employment at the facility ended on 01/04/2023. Licensee agreed to retrain its remaining direct care staff on Resident’s Personal Rights (as articulated in CDSS form LIC 613C-2), and to submit the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, Licensee’s staff (S1) did not treat 2 of 56 residents (R1 and R3) with dignity, which posed a potential personal rights risk to persons in care.
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Type B
02/04/2024
Section Cited
CCR87468.2(a)(1)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities: “(a)…residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (1) To have a reasonable level of personal privacy in…personal care and assistance…”
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Per manager interview and personnel records, S1’s employment at the facility ended on 01/04/2023. Licensee agreed to retrain its remaining direct care staff on Resident’s Personal Rights (as articulated in CDSS form LIC 613C-2), and to submit the training sign-in sheet to LPA, by the POC due date.
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This requirement was not met, as evidenced by: Based on records and interviews, Licensee’s staff (S1) did not uphold the personal privacy of 1 of 56 residents (R3), which posed a potential personal rights risk to persons 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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 01/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/05/2024
LIC809 (FAS) - (06/04)
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