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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 11/18/2022
Date Signed: 11/18/2022 03:45:30 PM


Document Has Been Signed on 11/18/2022 03:45 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:TRACY KNEPPLEFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 159DATE:
11/18/2022
TYPE OF VISIT:POCUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Executive Director, Tracy Knepple TIME COMPLETED:
12:25 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted a Plan of Correction visit. LPA met with Executive Director, Tracy Knepple and discussed the purpose of the visit, to follow up on a deficiency correction.

On 10/13/22, the facility was issued a deficiency regarding basic services requirements. The facility must be aware of the resident's general whereabouts, although the resident may travel independently in the community. On 10/06/22, Resident #1 (R1) eloped from the facility and the facility was not aware R1 eloped. The Executive Director (ED) put 24 hour supervision in place for R1. In addition, ED stated they would link the current notification system to alert staff when a door is opened. Today, LPA briefly toured the facility and observed notification system in place to alert staff when a door has been opened to an unsecured area. The plan of correction has been corrected.

No deficiencies were observed today, 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: 11/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/18/2022
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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