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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 02/08/2023
Date Signed: 02/09/2023 10:08:55 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/05/2023 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20230105085446
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: 163DATE:
02/08/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
12:25 PM
ALLEGATION(S):
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-Medications not given as prescribed
-Facility did not meet resident's incontinent needs
-Facility did not provide basic laundry services

INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud concluded the investigation regarding the above mentioned allegations. LPA discussed the findings 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 reported Resident #1 (R1) did not receive their medications on 12/25/22. R1’s Physician’s Report was not dated or updated, as R1 was receiving services from an outside agency for a medical condition that was not listed on the report. The report indicated R1 was able to communicate their needs, and required assistance with bathing, dressing/grooming, toileting, and medication management. The report also stated R1 was ambulatory but required extensive assistance. Facility’s assessment of R1 was conducted on 10/01/22 indicated R1 required escort service to and from the Wellness Center or Medication Cart to receive their medications. Staff voiced R1 received their medication on 12/25/22 and didn’t recall any missed medications. Staff interviews revealed they escort R1, included taking R1 to receive their medications before meals. Continued on an LIC 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
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 2
Control Number 08-AS-20230105085446
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 02/08/2023
NARRATIVE
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A review of R1’s Medication Administrative Records (MAR) for December 2022 also confirmed R1 received their medication on 12/25/22 and was logged in the computer system as dispensed. R1 has one prescribed pill and a topical cream on file. R1’s interview disclosed being aware of the one medication they take daily and refusal of the cream, as it was no longer needed. R1 denied not receiving their medication on 12/25/22. Resident interviews confirmed receiving their medications on 12/25/22. The Executive Director explained some staff called out sick on Christmas day, 12/25/22. However, the shifts were covered and their Director of Resident Services, who is a nurse also came in to assist on her day off, to ensure residents received their medications. Outside source interviews confirmed residents were receiving their medications.

It was also reported, the facility did not meet R1’s incontinent needs resulting in R1 sitting in soiled briefs. R1’s Physician’s Report indicated R1 did not have bowel/bladder impairment. R1’s assessment conducted by the facility on 10/01/22 regarding incontinent care reflected R1 received toileting reminders and assistance with personal hygiene. The documented instructions outlined on the assessment was to take R1 to the bathroom every 3-4 hours while awake and take the resident to the bathroom before and after meals and at bedtime. Staff confirmed R1 was taken to the bathroom as documented on the assessment. R1’s interview confirmed staff are meeting their incontinent needs. Residents interviews also confirmed the facility staff are meeting their incontinent needs. Outside source interviews confirmed residents incontinent needs are being met.

Lastly it was alleged, the facility did not provide basic laundry services for R1. It was reported R1’s authorized representative requested all of R1’s worn items be removed daily and washed. Outside source’s interview revealed R1’s laundry was also being done by the resident’s family as there was too much laundry and the facility was not washing enough. The facility’s policy is to launder resident’s items weekly unless otherwise specified. Facility’s Assessment dated 10/01/22 indicated personal laundry will be washed three (3) times a week at an additional charge, daily bed making, daily rash removal, launder bed linens and towels once per week, and housekeeping one day per week. Staff’s role also included cleaning the resident’s room and doing their laundry, which they confirmed is being followed through. R1’s interview confirmed staff are keeping the room clean and laundry is being kept up. Resident interviews confirmed housekeeping and laundry services are being provided by the facility and there are no issues. Outside source interviews confirmed residents are receiving housekeeping and laundry service to meet the resident's needs.

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 were deemed unsubstantiated. An exit interview was conducted and a copy of this report along with 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: 02/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023
LIC9099 (FAS) - (06/04)
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