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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 10/13/2022
Date Signed: 10/14/2022 08:22:42 AM


Document Has Been Signed on 10/14/2022 08:22 AM - 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:
10/13/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with Executive Director, Tracy Knepple and discussed the purpose of the visit, to follow up on incident reports..

During today's visit, LPA briefly toured the facility, requested records and interviewed staff and residents. The facility self reported two incidents. One incident occurred on 10/06/22 involving Resident #1 (R1). R1 eloped from the facility and was brought back by staff, no injuries were sustained. R1's Physician's Report indicated R1 cannot leave the facility unassisted, which is due to a Major Neurocognitive Disorder. Title 22 Regulations outline resident's that have a Major Neurocognitive Disorder require an annual medical assessment. R1's Physician's Report was dated 07/14/21. R1's Assessment dated 08/20/22, indicated R1 requires redirection for exit seeking behavior. The facility was aware R1 was not allowed to leave unassisted and had an exit seeking behavior but nothing was put in place to ensure R1's safety.

The second incident occurred on 10/08/22 involving Resident #2 (R2). R2 was found on the floor by staff and sustained multiple injuries. Facility staff called 911 and R2 was transported to the hospital and evaluated.

Deficiencies were observed and cited on the attached LIC 809D. An exit interview was conducted and a copy of this report, and Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Tracy Knepple 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: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
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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Document Has Been Signed on 10/14/2022 08:22 AM - It Cannot Be Edited

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: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/10/2022
Section Cited

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Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:
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Based on interviews, the licensee did not ensure the safety for (R1) 1 out of 148 residents. Staff were unaware R1 eloped from the facility. This poses a potential immediately health and safety risk to residents in care.
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Type B
11/10/2022
Section Cited

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Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
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Based on record review, the licensee did not ensure (R1) 1 out of 148 residents had a current Medical Assessment on file. This poses 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/13/2022
LIC809 (FAS) - (06/04)
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