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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 08/09/2022
Date Signed: 08/12/2022 05:19:53 PM


Document Has Been Signed on 08/12/2022 05:19 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: 148DATE:
08/09/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Executive Director, Inan Linton TIME COMPLETED:
12:20 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Other. LPA met with Executive Director, Inan Linton and Assistant Executive Director, Tracy Knepple and discussed the purpose of the visit.

During today's visit, LPA briefly toured the facility and observed some residents in care. A health and safety check was conducted. No deficiencies were observed during the visit.

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.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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 2


Document is an Amendment of Original Document on 08/12/2022 05:20 PM

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: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/09/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/12/2022
Section Cited

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This is an amended version of the original report created on 08/09/22. No deficiency was issued.
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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: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2