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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 05:00:21 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
08/06/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240806141711
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: 151DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility staff did not respond timely to resident's calls for assistance
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegation. LPA met with Executive Director, Tracy Knepple.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged facility staff did not respond timely to Resident #1’s (R1) calls for assistance. R1’s Physician Report dated February 13, 2024, indicated R1 had a Major Neurocognitive Disorder, bedridden status, and receiving hospice services. The report also reflected R1 required assistance with bathing, dressing/grooming, toileting, feeding, and medication management. R1’s Service Plan dated May 3, 2024, indicated R1 required assistance with bathing, dressing/grooming, toileting, feeding, two person transfers, and medication management. Facility’s PAL (Personal Assistance Liaison) Approach Chart and Service Plan dated June 2024 indicated R1 required assistance with toileting; feeding; medications; dressing; transfer assistance by two staff members/hoyer lift required. R1 resided in the memory care at the facility. 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-20240806141711
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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Per the Executive Director (ED), the residents in memory care do not have call pendants as they do not have the cognitive ability to push the call button. All resident rooms have a pull cord for assistance. Once the pull cord is activated, it alerts the staff’s pager. ED added R1 had a twenty-four (24) hour private companion, no reason for delay in care. R1 was not mobile, no safety risk if companion left R1’s room to go get additional support from facility staff.

Interviews with private companions revealed they would pull the pull cord and have to wait 30-60 minutes for staff to respond. A review of daily notes for March 2024 completed by the private companion indicated delay in care for R1. The daily notes also stated the private companion would pull the pull cord or have to go into the hall looking for facility staff to change and reposition R1. R1’s Call Light History log for February 2024, reflected multiple response times of six (6) hours; five (5) hours; four (4) hours; two (2) hours, and one (1) hour. R1’s Call Light History log for March 2024, reflected multiple response times of five (5) hours; six (6) hours; and four (4) hours. R1’s Call Light History log for April 2024, reflected multiple response times of over two (2) hours; R1’s Call Light History log for May and June 2024, reflected response times over forty-five (45) minutes. R1’s private companion reported delay in care for R1 during those reported times frames.

Staff interviews revealed they responded timely. Staff also stated R1 was a two (2) person assist and when R1 required assistance the caregiver would go to R1’s room and call for another caregiver to assist. Some caregiver interviews revealed once they arrived to R1’s room, R1’s private companion would assist with brief change and repositioning of R1. R1’s family obtained a private companion twenty-four (24) hours per day, in addition to the facility’s caregivers. The private companions were hired to provide companionship, not direct care. A review of private companion’s daily notes for March 2024 showed there were some occasions where the private companion pulled the pull cord for assistance and staff did not arrive to assist.

Based on interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is 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]

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-20240806141711
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
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 was not met as evidenced by:
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ED implemented a new policy regarding decreased response time. The facility purchased new staff communication equipment and provided training on the new policy and provided proof on 08/16/24. POC corrected.
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Based on record review, the licensee did not respond to 1 out of 155 [R1] residents’ requests for assistance in a timely manner. Some resident wait times were up to 6 hours for staff to respond to and restore pendants. This poses 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.
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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: 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
08/06/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240806141711

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: 151DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
03:41 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Neglect resulting in Stage 3 pressure injury
Neglect resulting in fracture
Facility staff did not follow resident's admission agreement
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff and outside sources. It was alleged, neglect resulting in fracture for Resident #1 (R1). R1’s Physician’s Report dated February 13, 2024, indicated R1 had a Major Neurocognitive Impairment, was bedridden and required assistance with bathing, toileting, dressing/grooming, feeding, medication management and receiving hospice services. R1’s Service Plan dated May 3, 2024, indicated R1 required assistance with bathing, dressing/grooming, toileting, feeding, two person transfers, and medication management. On February 3, 2024, R1 was in a common room at the facility getting ready to watch a movie with other residents. R1 was witnessed getting up out of their wheelchair, tripping on their footrest and falling on the floor. When R1 fell, they also hit their head on a side table and the floor. A facility nurse immediately went to render aid and assessed R1. 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: 4 of 6
Control Number 08-AS-20240806141711
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 nurse reported R1 was complaining of head pain as well as leg pain. The nurse’s interview revealed it was facility policy to send a resident out for evaluation when they hit their head. Therefore, the facility contacted 911. The nurse also reported R1’s responsible party was upset that R1 was sent out for medical evaluation before calling R1’s responsible party and the nurse explained it was their policy.

On February 3, 2024, R1 was transported to hospital and diagnosed with a fractured hip. R1 was recommended to go to a Skilled Nursing Facility (SNF) after being discharged from the hospital. The Director of Resident Care Services (DRCS) explained R1’s responsible party refused and didn’t want R1 going to a SNF due to a bad experience. The Executive Director (ED) advised R1’s family that R1 could return back to the facility if R1 was placed on hospice and if they hired a 24/7 caregiver to take care of R1, which R1’s responsible party agreed. On February 11, 2024, R1 was admitted back to the facility and placed on hospice care with around the clock care giving services provided by facility staff and an outside agency. The facility staff acted appropriately with the fall and as soon as head trauma was determined, 911 was immediately called with no hesitation.



It was also alleged neglect resulting in Stage three (3) pressure injury for R1. On February 3, 2024, R1 fell at the facility and was transported to the hospital. On February 11, 2024, R1 returned to the facility, and it was reported R1 sustained a pressure injury on their coccyx that was covered with a dressing. The facility’s DRCS stated after R1’s fall they became bedridden and unable to walk on their own, and R1’s hospice agency was required to provide wound care one (1) to two (2) times a week. DRCS explained R1’s pressure injury would shift between a Stage one (1) and a Stage two (2) constantly. DRCS also stated R1’s pressure injury was right on their backside which didn’t help with healing because every time R1 had a bowel movement it would get soiled. DRCS’ interview revealed the facility’s policy allows residents to remain in the facility with wound/pressure injuries if the wound is lower than a Stage one (1) or Stage two (2). However, once the wound progresses to a Stage three (3), that is considered a prohibited health condition, and the resident must be sent out to a SNF until the wound/pressure injury is healed.

The Wound Specialist’s interview revealed it was hard to get R1 to cooperate at times and R1 didn’t like assistance. The Wound Specialist also confirmed R1’s wound started out as a Stage two (2) and progressively got worse because it was one of those challenging areas and it was hard to keep R1 off their back. On July 3, 2024, the hospice agency advised that R1’s pressure injury progressed to a Stage three (3). 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: 5 of 6
Control Number 08-AS-20240806141711
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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On July 4, 2024, the ED, DRCS and Wound Specialist all met to discuss R1’s pressure injury and the possibility of it progressing to a worse stage quickly if R1 isn’t seen by medical professionals. R1’s pressure injury wound had eschar (a dry, crusty layer of dead tissue that forms on the surface of a wound, according to the Mayo Clinic) and redness around it, a non-emergency transport was scheduled to take R1 to the hospital for further evaluation.

ED’s interview revealed R1’s responsible party was not pleased with R1 being sent to the hospital. The DRCS reported they discovered R1’s pressure injury got aggressive while R1 was at the hospital, and R1 required a wound vac. After R1’s hospitalization, they did not return to the facility. The Wound Specialist commented that sending R1 to the hospital for evaluation was the right thing to do because if R1 would have remained at the facility, the pressure injury would have gotten worse. The facility was in communication with the hospice agency and followed their direction by seeking professional assistance for R1’s medical care. The facility ensured R1 received required medical treatment for R1’s pressure injury.

Lastly, it was also alleged facility staff did not follow R1’s admission agreement. It was reported R1’s responsible party was being over charged by paying for additional caregivers. Outside source interviews revealed R1’s responsible party was paying for hospice services, private companions 24 hours a day, and extra money for an additional facility staff to be available to assist the private companions, whenever they needed it.

R1’s Admission Agreement dated July 30, 2021, indicated a basic rate with no additional support. The facility issued an Amendment to Resident Service Agreement for Change in Residence dated February 21, 2023. The change reflected R1 required Enhanced Personal Care I with a charge of $1150, in addition to the basic rate. The Admission Agreement reflected Enhanced Personal Care I included hands on assistance with showering more than four times per week, transfer assistance by one (1) staff member and any service included in basic personal care. However, R1 was receiving showers/bathing from hospice agency staff. The ED’s interview revealed R1 was receiving Enhanced Personal Care II, which required a two (2) person assist but the documentation reflected Enhanced Personal Care I. The facility followed the Admission Agreement by providing notice to the resident/responsible party of the increase charge of $1150, which was signed by the responsible party, agreeing to the additional charge.

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 allegations. The allegations are 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