<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 04/17/2023
Date Signed: 04/17/2023 12:55:56 PM


Document Has Been Signed on 04/17/2023 12:55 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:
04/17/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director Tracy Knepple and Director of Resident Care Services Christina WitcherTIME COMPLETED:
01:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit to cite a deficiency identified during an prior visit. LPA was welcomed by and identified himself to Concierge Diane Forsythe. LPA then met and discussed the purpose of the visit with Executive Director Tracy Knepple and Director of Resident Care Services Christina Witcher.

On 03-13-2023, licensee self-submitted an LIC624 Incident Report to the CCLD San Diego Regional Office. The LIC624 described an AWOL (absent without leave) event involving Resident #1 (R1), which occurred on the morning of 03-07-2023. [See LIC811 Confidential Names List for a description of R1.] Law enforcement located R1 around 1 to 1.5 hours later, unharmed/uninjured.

On 03-14-2023, LPA conducted a site visit to follow up on the LIC624. LPA interviewed R1, verifying that they were indeed unharmed/uninjured. LPA also interviewed relevant staff and outside sources and reviewed pertinent records.

According to R1's LIC624 Physician's Report, dated 02-24-2023, R1's primary diagnosis was Dementia and their doctor determined that they were unable to safely leave the facility unassisted. R1's LIC603 Pre-Placement Appraisal, dated 02-20-2023, reiterated R1's dementia diagnosis and said they needed help navigating about the facility. The care plan/assessment which licensee prepared on R1 instructed their staff to observe R1, due to risk of "wandering" and/or "exit seeking."

Interviews revealed: on 03-07-2023, staff escorted R1 to the facility's main assisted living dining room to eat breakfast. After eating, R1 exited not just the dining room, but also the facility building itself, without staff being aware. Staff #1 (S1), who on the morning of the incident was stationed inside the facility lobby (which is adjacent to the dining room), confirmed: a) they knew what R1 looked like; and b) they did not see R1 exit the facility via the lobby's main front doors. [CONTINUED ON LIC 809-C]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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
VISIT DATE: 04/17/2023
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During his 03-14-2023 site visit, LPA observed the dining room in question had one perimeter exit door which led directly to outside the building. Absent from this door was either an "auditory device" or other "staff alert feature."

During today's visit, LPA accompanied by staff, briefly toured the facility to again observe other exit doors. This included observation/testing of the four (4) delayed-egress doors located within the facility's secured memory care unit (which licensee calls "The Neighborhood"). LPA observed that for two (2) of these doors (i.e., Neighborhood "South East" and "Dining Room" delayed-egress doors), there was no sign present meeting the requirements of California Health and Safety Code Section 1569.699(a)(7)(A).

One (1) deficiency was cited per California Code of Regulations, Title 22, and one (1) deficiency was cited per California Health and Safety Code (refer to the attached LIC 809-D). Plans of Correction were jointly developed with the licensee.

An exit interview was conducted with Knepple and Witcher, to whom a copy of this report, the LIC 809-D, the LIC811 Confidential Names List, and the Licensee/Appeal Rights (LIC9058 03/22) were provided.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 04/17/2023 12:55 PM - 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: 04/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/17/2023
Section Cited

1
2
3
4
5
6
7
87705 Care of Persons with Dementia: “(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.” This requirement was not met, as evidenced by:
1
2
3
4
5
6
7
Licensee agreed to install and test an auditory device (or similar staff alert device) on the inside of the door, which leads from its assisted living dining room to outside the building. Licensee agreed to send LPA a video recording demonstrating the device in place and working, by the POC due date.
8
9
10
11
12
13
14
Based on records and interviews, the licensee did not have an auditory device or other staff alert feature to monitor one of its exits, which posed a potential safety risk to 1 of 169 residents (R1) in care.
8
9
10
11
12
13
14
Type B
05/17/2023
Section Cited

1
2
3
4
5
6
7
1569.699 Exit doors; egress-control devices of time-delay type; fences: "(a)(7)(A) A sign shall be provided on the door located above and within 12 inches of the panic bar or other door-latching hardware reading: KEEP PUSHING. THIS DOOR WILL OPEN IN ___ SECONDS. ALARM WILL SOUND."
1
2
3
4
5
6
7
Licensee agreed to install signs [meeting the requirements of Health and Safety Code Section 1569.699(a)(7)(A)] on the "South East" and "Dining Room" delayed-egress doors (both located within its "Neighborhood" memory care unit). Licensee agreed to send LPA photos demonstrating the signs on both doors, by the POC due date.
8
9
10
11
12
13
14
Based on records and interviews, the licensee did not have a sign reading "KEEP PUSHING. THIS DOOR WILL OPEN IN ___ SECONDS. ALARM WILL SOUND" on two (2) of its four (4) delayed egress doors within its memory care unit. This posed a potential safety risk to 24 of 159 residents in care.
8
9
10
11
12
13
14
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: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 04/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/17/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3