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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 07/01/2022
Date Signed: 07/06/2022 04:22:02 PM


Document Has Been Signed on 07/06/2022 04:22 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:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 152DATE:
07/01/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Executive Director, Inan LintonTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA met with Executive Director, Inan Linton and we discussed the purpose of the visit.

During today's visit, LPA briefly toured the facility, obtained records, and interviewed staff and residents. On 06/30/22, the facility self-reported an elopement involving Resident #1 (R1). The elopement occurred on 06/27/22. According to R1's Physician Report, R1 is not allowed to leave the facility unassisted. R1 was located and returned to the facility without injuries. The facility followed their Absentee Notification Plan. No deficiencies were issued today.

An exit interview was conducted and a copy of this report, and Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Inan Linton whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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