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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 08/05/2025
Date Signed: 08/05/2025 10:14:01 AM

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
06/12/2025 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20250612101952
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: 150DATE:
08/05/2025
UNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Staff forcefully administered medication to resident in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced 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, residents, and outside sources. It was alleged that staff forcefully administered medication to a resident in care. It was reported a nurse/area manager forcefully administered an insulin injection to Resident #1 on 06/10/25. R1 receives medication management from the facility staff. Staff interviewed reported R1 was known for refusing medications but not their insulin. A review of R1’s Medication Administration Records (MARs) for June 2025 indicated R1 refused medications and or insulin on 06/01/25; 06/02/25; 06/08/25; and 06/10/25. Further staff interviews showed that R1 had agitation at times and will refuse medications. Facility’s Progress Notes dated 06/10/25 indicated R1 was agitated and did not want to take their medications. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
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 3
Control Number 08-AS-20250612101952
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: 08/05/2025
NARRATIVE
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It also stated that R1 continued to verbalize “don’t touch me, I don’t want anything done” and that the nurse was able to provide medications at noon. However, the MARs were documented on 06/10/25 that the medication/insulin was administered in the morning, not noon, and signed off by the nurse. The interview conducted with the nurse/area manager confirmed R1 didn’t want to take anything, but the nurse/area manager stated they were able to have a discussion to coax R1 to take it, then R1 agreed. The nurse/area manager explained they administered two injections quickly to R1 but not forcefully. Staff interviews revealed that R1 said they didn’t want their medications. The nurse/area manager was witnessed pulling R1’s sleeve up and administering the insulin, while R1 was stating they didn’t want it. It was reported R1 left crying. R1 was not interviewed due to a Major Neurocognitive Disorder and no longer residing at the facility. On 06/12/25, R1 moved out of the facility.

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. [See LIC 811 Confidential Names List to identify Resident #1]

SUPERVISORS NAME: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Citations on this Visit Report are Under Appeal!

Control Number 08-AS-20250612101952
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: 08/05/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Under Appeal
Type B
09/02/2025
Section Cited
CCR
87468.1(a)(16)
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Personal Rights of Residents in All Facilities. Residents in all residential care facilities for the elderly shall have all of the following personal rights: To receive or reject medical care or other services. This requirement is not met as evidenced by:
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Executive Director agreed to have all staff that administer medications including the regional nurse/area director of clinical services attend personal rights training by an outside vendor and submit proof of training by POC due date.
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Based on interviews and records, the licensee did not allow 1 out of 149 [R1] residents to refuse their medications/insulin, which posed a potential safety and personal 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: Lizzette Tellez
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/05/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/05/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3