Complaint Investigation Report, 10/08/2025 — Grossmont Gardens Memory Care, La Mesa CA

It was alleged that staff did not meet the incontinence care needs of residents. More specifically, the Reporting Party (RP) reported that during the night, they found seven residents double diapered and very wet when providing incontinence care. RP stated that despite reporting this to management, the issue persisted. Staff interviews revealed that incontinence care was provided per schedule and that double-diapering was not a standard practice. Resident interviews revealed no concerns regarding incontinence care. Records review revealed that incontinence care schedules and staffing assignments were consistent with regulatory requirements. The Department’s observations revealed that residents were not observed in soiled or double-diapered conditions during visits conducted around the time of the allegation.

It was further alleged that staff did not meet residents’ bathing needs. More specifically, RP stated that staff were not assisting residents with showers. Staff interviews revealed that showers were being provided according to the facility’s schedule. Resident interviews revealed no concerns regarding bathing assistance. Records review revealed that shower schedules and hygiene documentation were consistent with regular bathing practices. The Department’s observations revealed that residents appeared clean and well-groomed during visits conducted around the time of the allegation.

It was further alleged that staff did not ensure residents had clean linens. More specifically, it was alleged that management instructed staff not to change soiled linens for two to three days due to excessive laundry. Staff interviews revealed that while one staff member reported delays in linen changes due to laundry volume, no staff confirmed that this was a directive from management. Resident interviews revealed no concerns regarding the cleanliness of their bedding. Records review revealed that laundry schedules and linen inventory logs for July 2023 did not reflect any service delays. The Department’s observations revealed that resident beds had clean linens with no visible soiling or odors during visits conducted around the time of the allegation.