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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 06/01/2023
Date Signed: 06/01/2023 02:23:54 PM


Document Has Been Signed on 06/01/2023 02:23 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: 161DATE:
06/01/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Executive Director Tracy Knepple and Director of Resident Care Servics Christina WitcherTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tracy Knepple and Director of Resident Care Services Christina Witcher.

On 08/25/2021, the CCLD San Diego Regional Office met with the licensee for a Non-Compliance Conference (NCC). During today’s visit, LPA conducted a general tour of the facility, performed a welfare check on residents in care, interviewed relevant staff, reviewed training records, and evaluated licensee’s ongoing compliance with the actions/objectives that they agreed to during the NCC.

LPA also provided technical assistance/education on these sections from Title 22 of the California Code of Regulations: 87465 Incidental Medical and Dental Care, 87609 Allowable Health Conditions, 87411 Personnel Requirements, and 87616 Exceptions for Health Conditions. LPA also provided licensee with CCLD’s Pressure Injuries Guide publication (version 04/04/2019).

During today’s visit, the facility was clean, safe, sanitary, and in good repair. There were no immediate health or safety concerns. No deficiencies were observed or issued as part of this compliance visit.

An exit interview was conducted with Knepple and Witcher, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 06/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/01/2023
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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