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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 04/10/2025
Date Signed: 04/10/2025 04:50:40 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/12/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250312121604
FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:TRACY KNEPPLEFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Medications not given as prescribed
Licensee did not ensure resident medication records were accurate
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Executive Director, Tracy Knepple.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged medications were not given as prescribed for Resident #1 (R1) and Resident # 2 (R2). It was reported R1 was not given the correct dose of morphine, R2 was provided medication patches that belonged to Resident # 3 (R3), and medications were missing. R1 was receiving hospice services. Staff interviews revealed hospice was changing the morphine orders from half tab to full tab and back to half tab, as frequent as three (3) times in one (1) week. Staff explained the medication orders went directly to the pharmacy contracted by the facility. Once the order was placed, it appeared in their medication administration system, ACCUflo. Staff followed the ACCUflo system to administer medications. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 6
Control Number 08-AS-20250312121604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 04/10/2025
NARRATIVE
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The facility’s Controlled Drug Record for March 2025 indicated the morphine was given. However, the Medication Administration Record (MAR) does not match based on the doses and dates. R2 had prescribed patches as well as R3. R2 resided in the assisted living portion of the facility and R3 resided in the secured memory care unit. Staff interviews revealed as they were going to administer/apply the patch to R2, when they observed the already applied patch was incorrect. Staff stated the patch was different in size, so they checked the milligrams and noticed it was 9.6mg, instead of prescribed 4.6mg. Staff’s interviews confirmed the medication was not given as prescribed, as it was for another resident. Staff stated three residents within the facility had a prescription for patches and only R2 and R3 were prescribed the same medication name but different doses. LPA was unable to observe the patches, as the facility had them destroyed.

It was also alleged licensee did not ensure resident medication records were accurate. R1’s morphine prescription was frequently changing doses from 1 full tab to 1 half tab and back and forth, within a short period of time. Due to the facility’s medication technician cutting a full tab into a half tab, documentation was required to account for the wasted half tab. The nurse’s interview confirmed when a medication is wasted or not given, it’s documented on the Medication Administration Record, not the Controlled Drug Record and destroyed using the drug buster. A review of R1’s Controlled Drug Record indicated on 03/09/25, a pill was wasted but didn’t reflect how much was wasted or why. Some staff interviews revealed they were not sure where to log the wasted pill. An email dated 03/26/25 from the facility’s Senior Vice President, Regulatory Affairs confirmed the staff failed to document the half pill destruction on the morphine log. The email also stated extensive mandatory training for all staff assisting with medication administration will be conducted. Med Tech interview confirmed they destroyed the wasted half pill but forgot to document it on the destruction record. The wasted pill was documented on the Control Drug Record, dated 03/09/25. However, none of the other wasted pills were documented on that record. According to the facility’s Morphine and MAR Audit log for March 1-10, 2025, there were six wasted pills, and they were not documented on the Controlled Drug Record. Per staff, wasted pills are documented on the Destruction Record, not the Controlled Drug Record, even though it was documented as wasted for 03/09/25. A review of R1’s MARs reflected multiple morphine prescriptions regarding full and half tab. It was unknown if pills that were wasted were considered missing, as the staff indicated medications not used are destroyed in the drug buster, which is a solution to destroy medication. Continued on an LIC 9099C.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20250312121604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 04/10/2025
NARRATIVE
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The Controlled Drug Record for 03/07/25 showed full tab of morphine was administered three (3) times; half tab was administered two (2) times. However, the MAR does not match the Controlled Drug Record. The MAR for 03/07/25 showed only four half tabs were dispensed that day. The MAR did not have an order to dispense full tab for 03/07/25. The MAR had an order of half tab every 6 hours that started on 03/05/25 and was discontinued on 03/08/25. The Controlled Drug Record for half tab dispensed on 03/07/25, indicated half tab every 4 hours. There was no order on the MAR for a full tab to dispense on 03/07/25, as the orders were probably pending with the frequent changes. It is unknown if R1 received correct doses due to the discrepancies between the MAR and the Controlled Drug Record. Nurses and Medication Technician’s confirmed the wasted pills are documented on the destruction record, not the Controlled Drug Record.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. A civil penalty was assessed for a repeat violation within a 12 month period. [See LIC 811 Confidential Names List to identify Resident #1, #2, and #3]
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/12/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250312121604

FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:TRACY KNEPPLEFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
02:41 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
03:40 PM
ALLEGATION(S):
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Staff cut resident's medication without an order
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation. LPA met with Executive Director, Tracy Knepple.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff cut resident's medication without an order. It was reported a Medication Technician cut a morphine pill for R1. R1’s morphine doses were being changed frequently. Staff interviews revealed they were unable to locate the half tab of morphine. Therefore, they cut the full tab into half, in order to follow correct dosing. Director of Resident Care Services (DRCS), interview revealed they can cut the scored pill if there’s an order, but it must be cut by a nurse, which is Belmont’s policy. A review of records indicated there was no order on file to cut the pill. Further staff interviews confirmed only a nurse can cut a scored pill in order to provide correct dosing. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20250312121604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 04/10/2025
NARRATIVE
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Medication Technician admitted to cutting the pill without the order and stated the nurse was aware. The nurse’s interview confirmed the medication technician was provided approval to cut the pill and the nurse witnessed the pill being cut. The facility was able to cut the pill to ensure the correct dose was being administered to R1. Director of Resident Care Services' interview revealed if the order is for half tab but they have full tab, they can cut it, because it’s according to medication dosing. As long as the correct medication is administered, it’s not a concern. Even though there wasn't an order on file to cut the pill, there was an order for a half pill dose. The pill was not cut in order to camouflage but to administer the correct dose.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 6
Control Number 08-AS-20250312121604
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

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

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/10/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/10/2025
Section Cited
CCR
87465(a)(4)
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Incidental Medical and Dental Care. A plan for incidental medical...be developed by each facility. The plan shall encourage routine medical...by compliance with the following: The licensee shall assist residents with self-administered medications as needed.
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Executive Director (ED) was proactive and had staff attend medication training. ED submitted proof of training. POC corrected.
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This requirement is not met as evidenced by:
Based on interviews, the licensee did not ensure medications were given as prescribed for 2 out of 152 [R1-R2] residents, which posed a potential health and safety risk to residents in care.
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A civil penalty was assessed for a repeat violation within a 12 month period.
Type B
04/10/2025
Section Cited
CCR
87506(a)
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Resident Records. A separate, complete, and current record shall be maintained for each resident in the facility, readily available to facility staff and to licensing agency staff and shall contained specified information. This requirement is not met as evidenced by:
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Executive Director (ED) was proactive and had staff attend medication training regarding medication documentation. ED submitted proof of training. POC corrected.
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Based on interviews and record review, the licensee did not ensure a complete MARs was maintained 1 out of 152 [R1] residents, which posed 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.
SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 6