374603279-6-10-2022-08-AS-DPOL-CFVNCB-20220630102025

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 06/10/2022
Date Signed: 06/10/2022 09:44:31 AM

Substantiated

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
01/24/2022 and conducted by Evaluator Esther Miller

PUBLIC

COMPLAINT CONTROL NUMBER: 08-AS-20220124114252

FACILITY NAME:	BELMONT VILLAGE SABRE SPRINGS		FACILITY NUMBER:	374603279
ADMINISTRATOR:	INAN LINTON		FACILITY TYPE:	740
ADDRESS:	13075 EVENING CREEK DR S		TELEPHONE:	(858) 486-5020
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	184	CENSUS: 154	DATE:	06/10/2022
		UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Inan Linton, Executive Director		TIME COMPLETED:	10:08 AM

ALLEGATION(S):

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Facility is not following COVID-19 guidelines.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Esther Miller conducted an unannounced complaint investigation visit to the facility in order to deliver findings on the above allegation. LPA was granted entry to the facility by Inan Linton, Executive Director, after identifying themselves and explaining the reason for the visit.

On January 24, 2022, it was alleged that the facility was not requiring negative COVID tests to enter the facility. The Department’s investigation consisted of LPA observations, review of facility records, and interviews of facility staff and outside sources.

[Continued on LIC9099-C]

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20220124114252

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: 06/10/2022

NARRATIVE

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[Continued from LIC9099]

On January 18, 2022, the Department released PIN 22-04-ASC in which facilities were required to ask and document visitor’s vaccination cards and negative COVID tests in order to visit indoors. This requirement ended on February 7, 2022 when the Department released PIN 22-07-ASC in which facilities were required to ask and document visitor’s vaccination card or negative COVID tests.

On February 2, 2022, LPA Miller arrived at the facility to open the complaint investigation and she observed two different visitors that did not provide negative COVID tests and were permitted to enter the facility. The facility utilized a system called AccuShield to document visitors, their COVID screening answers, and their vaccination cards. Facility’s visitation log, obtained from AccuShield data, showed a total of 248 visitors from January 18, 2022 to February 7, 2022. The log only reflected visitor’s answers to COVID screening questions and their vaccination cards.

Facility records also revealed a document that contained 109 entries of antigen COVID tests for staff and visitors from January 7, 2022 to March 8, 2022. Executive Director Inan Linton stated that the document contained mostly staff and 7 unique visitors that did not have a vaccination card at the time of their visit. These visitors visited between January 18, 2022 and February 3, 2022. Visitors tested negative for COVID and were allowed to enter the facility without also providing proof of vaccination. Executive Director stated that all other visitors from January 18, 2022 to February 7, 2022 were not asked to provide a negative COVID test to enter the facility.

Based on the evidence obtained during the complaint investigation, the allegation that the licensee did not follow COVID-19 guidelines as dictated by the Department is found to be SUBSTANTIATED, as there is a preponderance of evidence to show that the allegation occurred. Pursuant to the California Health and Safety Code, Division 2, Article 8, deficiency is being cited on the attached LIC9099D and a plan of correction was jointly developed with Executive Director. An exit interview was conducted with Inan Linton, Executive Director; a copy of this report and Licensee's Rights (LIC9058 were provided to Executive Director.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 08-AS-20220124114252

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: 06/10/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 06/30/2022 Section Cited CCR 87468.1(a)(2)	1 2 3 4 5 6 7	PERSONAL RIGHTS OF RESDIDENTS IN ALL FACILITIES: (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Executive Director will to submit Infection Control Plan by POC date.
	8 9 10 11 12 13 14	Based on interviews, observations, and record reviews, the licensee did not provide safe and healthful accommodations in 154 of 154 residents which posed a potential personal rights risk to residents in care.	8 9 10 11 12 13 14	This is an amended report.
	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.

SUPERVISOR'S NAME: Denise Powell	TELEPHONE: (619) 767-2317
LICENSING EVALUATOR NAME: Esther Miller	TELEPHONE: 619-767-2301
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022

LIC9099 (FAS) - (06/04)

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