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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 10/16/2020
Date Signed: 10/30/2020 05:36:48 PM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/17/2019 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20190917143342
FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:MARY JANE RODRIGUEZFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 112DATE:
10/16/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director, Inan LintonTIME COMPLETED:
01:10 PM
ALLEGATION(S):
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-Staff’s driving caused injury to resident while in transit
-Staff not responding to residents call button
-Resident did not receive bathing assistance from staff
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud contacted the facility to conclude a complaint investigation via telephone due to COVID-19. The tele virtual visit was conducted on 10/30/20 with Executive Director, Inan Linton.

During the investigation, a tour of the facility was conducted along with interviews with staff, residents, and outside sources, and records reviewed. It was alleged on 09/15/19, Resident #1 (R1) sustained an injury, while being transported back to the facility by Staff #1 (S1). The facility has a van/bus, which is driven by S1 to transport residents for outside activities. Interviews revealed S1 quickly pulled into the facility’s parking lot causing R1’s arm to hit the arm rest on the wheelchair. R1 sustained bruising and a 4-inch laceration below their right elbow, which was handled via first aid by the facility’s nurse. S1’s interviews revealed the bus was traveling at approximately 10 mph or less, upon entry into the facility’s driveway. Further interviews revealed the bus is top heavy and doesn’t have the best suspension system. Therefore, when the turn was made into the circular driveway, the van/bus hit the curb causing injury to R1. Continued on an LIC 9099C. This is an amended version of the original report created on 10/30/20.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
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 7
Control Number 08-AS-20190917143342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 10/16/2020
NARRATIVE
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Facility staff verified R1’s wheelchair was secured but the wheelchair tipped and caused injury. The facility conducted an internal investigation and discovered S1 was speeding. S1 was suspended and written up for the incident. Additional staff interviews confirmed S1 was driving too fast, hit the curb, and the wheelchair tipped causing injury to R1.

It was also alleged; staff are not responding to resident call buttons/pendants. R1’s interview revealed being left on the toilet for 30 minutes waiting for staff to arrive once the pendant was activated. Additional resident interviews confirmed waiting on the toilet for 45 minutes for staff to assist with transfer off the toilet. The facility's pendant log for September 2019 reflected 2664 pendant activations. The average response times were from 10 minutes to 60 minutes and at times up to 4 hours. Further interviews revealed the facility is short staffed and Resident #2 (R2) had to wait 45 minutes for escort to breakfast. Resident interviews confirmed waiting from 10 minutes up to 1 hour for staff to respond once the pendant was activated. Staff interviews revealed once the pendant is activated, the resident may wait 10-20 minutes, which staff feel is reasonable.

Lastly, it was alleged, Resident #3 (R3) did not receive bathing assistance from staff. R3 required assistance with bathing. R3’s Admission Agreement (AA) dated 04/20/18 indicated R3 required Personal Care to include standby shower assistance- assistance in and out of the shower at scheduled times up to three times per week. R3’s Resident Assessment and Service Plan, dated 01/05/20 reflected their bath schedule was Monday, Wednesday, and Saturday. The service plan outlined bathing is hands on assist with showers including washing back and feet and set up assistance with shower. Resident interviews revealed staff were unable to assist residents, as there are too many residents to care for. Staff interviews revealed residents are receiving showers according to their AA. R3’s interview revealed their showers were on Monday, Wednesday, and Friday's during the PM shift. Investigation revealed most times the staff were calling off and no one was available to shower R3 on their assigned day. Therefore, if R3’s shower was scheduled for Monday and staff were not available, R3 had to wait until Wednesday because Tuesday's are other resident's scheduled shower days. Therefore, staff were assisting residents with showers scheduled for Tuesday. R3 revealed there were many occasions R3 only received 2 showers per week, which conflicts with the AA. Continued on an LIC 9099C. This is an amended version of the original report created on 10/30/20.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20190917143342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 10/16/2020
NARRATIVE
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Based on interviews conducted, the preponderance of evidence standard has been met, therefore the above mentioned allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted with Executive Director, Inan Linton, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent by the Executive Director upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1, Resident #2, Resident #3 and Staff #1] This is an amended version of the original report created on 10/30/20.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20190917143342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/31/2020
Section Cited
CCR
87411(a)
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Personnel Requirements - General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by:
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Executive Director (ED) stated additional driver safety training will be provided to all drivers. ED will schedule training by correction date and provide proof once completed. This is an amended version of the original report created on 10/30/20.
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Based on interviews, the licensee did not ensure Staff were competent to provide transportation services to residents. This poses an immediate health and safety risk to residents in care.
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Type B
11/16/2020
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).
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Executive Director stated she will submit an LIC 500 Personnel Report to reflect staffing to ensure they are sufficient in numbers.
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Based on interviews and record review, the licensee did not ensure the staff were sufficient in numbers to meet the needs of the residents. This poses 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: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20190917143342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/16/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/16/2020
Section Cited
HSC
1569.312
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Basic services requirements. Every facility required to be licensed under this chapter shall provide at least the following basic services: Assistance with instrumental activities of daily living in the combinations which meet the needs of residents.
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Executive Director stated she will provide staffing schedules to ensure staff are available to provide required and agreed upon showers for residents. This is an amended version of the original report created on 10/30/20.
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This requirement is not met as evidenced by: Based on interviews and record review the licensee did not ensure the basic needs were met for R3. This poses 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: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 5 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
09/17/2019 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20190917143342

FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:MARY JANE RODRIGUEZFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: DATE:
10/16/2020
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:TIME COMPLETED:
01:10 PM
ALLEGATION(S):
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2
3
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5
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9
Staff left resident soiled in urine for extended period of time
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Natasha Persaud contacted the facility to conclude a complaint investigation via telephone due to COVID-19. The tele virtual visit was conducted on 10/30/20 with Executive Director, Inan Linton.

During the investigation, a tour of the facility was conducted along with interviews with staff, residents, and outside sources, and records reviewed. It was alleged Resident #1 (R1) was being left in soiled diapers for up to 30 minutes. Resident interviews revealed once the pendant is activated, it takes staff up to 30 minutes to respond, resulting in R1 sitting in a soiled diaper. R1’s Physician's Report, dated 07/17/18 reflected R1 has Bladder Impairment with some episodes of incontinence. R1’s Resident Assessment and Service Plan dated 04/01/19 indicated under Continence and Toileting that R1 requires toileting reminders and assistance with personal hygiene. Additional resident interviews revealed they have not witnessed other residents sitting in soiled urine for an extended period of time. Staff interviews revealed they have not witnessed residents soiled for extended periods of time. Further staff interviews revealed once the resident activates their pendant, the response time is up 20 minutes. Continued on an LIC 9099C. This is an amended version of the original report created on 10/30/20.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20190917143342
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 10/16/2020
NARRATIVE
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Based on interviews conducted we are unable to confirm or deny if staff are leaving residents in soiled urine for an extended period of time. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. An exit interview was conducted with Executive Director, Inan Linton, via virtual visit, and a copy of this report, along with Licensee/Appeal Rights (LIC 9058 01/16), were provided to the Executive Director via electronic mail. An electronic read receipt confirmation was requested to be sent by the Executive Director upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1] This is an amended version of the original report created on 10/30/20.
SUPERVISOR'S NAME: Rebecca HedgecockTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2020
LIC9099 (FAS) - (06/04)
Page: 7 of 7