374603279-10-20-2023-08-AS-LTEZ-CWZTM6-20231027145038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 10/20/2023
Date Signed: 10/20/2023 04:20:28 PM

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
08/21/2023 and conducted by Evaluator Natasha Persaud

COMPLAINT CONTROL NUMBER: 08-AS-20230821160039

FACILITY NAME:	BELMONT VILLAGE SABRE SPRINGS		FACILITY NUMBER:	374603279
ADMINISTRATOR:	TRACY KNEPPLE		FACILITY TYPE:	740
ADDRESS:	13075 EVENING CREEK DR S		TELEPHONE:	(858) 486-5020
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY:	184	CENSUS: 153	DATE:	10/20/2023
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Executive Director, Tracy Knepple		TIME COMPLETED:	01:00 PM

ALLEGATION(S):

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-Lack of supervision resulting in resident wandering from the facility
-Staff did not treat resident with dignity
-Staff can’t communicate with residents due to language barrier
-Staff mismanaged residents’ medication
-Staff did not meet resident’s medical needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the investigation regarding the above mentioned allegations. 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 lack of supervision resulting in Resident #1 (R1) wandering from the facility. R1’s Physician's Report dated 06/15/23 indicated R1 had a Major Neurocognitive Disorder, confusion, wandering behavior, able to follow instructions, and was not allowed to leave the facility unassisted. R1 resided in the secured memory care unit with delayed egress doors. The delayed egress doors have signs that state “Push and hold for 15 sec. Alarm will sound door will open in 15 seconds.” R1 would read the sign, push, and hold, and once the door opened, R1 exited. Staff interviews confirmed R1 would read the sign and follow the directions then exit. There were two occasions 08/13/23 and 08/17/23, when R1 exited the delayed egress doors and walked out of the facility. Continued on an LIC 9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230821160039

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: 10/20/2023

NARRATIVE

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On both occasions, staff were present with R1 and had line of sight supervision. As staff were following R1, they stayed on the phone with the manager in charge providing details and location. Staff interviews confirmed R1 was safe with staff and did not sustain any injuries. Staff also confirmed they never lost sight of supervision with R1. Evidence obtained revealed there was no lack of supervision, as staff were present with R1 the entire time R1 was out of the facility and in the community.

It was also alleged staff did not treat R1 with dignity. Outside source interviews revealed staff were rude to R1 by telling R1 to get back in their room and close the door. Staff interviews revealed R1 had family visiting frequently with small dogs that were not leashed. Therefore, staff asked R1 to go back into their room and close the door. Staff explained being worried about the other resident’s safety because the residents could trip on the small dogs or their leashes, plus some feared dogs. Resident interviews confirmed they were treated with dignity by staff.

It was also alleged staff can’t communicate with residents due to a language barrier. Outside sources reported some staff do not speak English. Staff interviews revealed there were no language barriers, as all staff spoke English. The Human Resources Generalist explained speaking English is a requirement for the job. Therefore, all staff speak English. Additional outside source interviews confirmed there was no language barriers with staff and have been able to discuss resident care needs. Resident interviews confirmed they understand staff and there were no language barriers.

It was also alleged staff mismanaged residents’ medication. Outside sources reported Resident #2 (R2) shared the same first name as R1 and R2 was given R1’s medications. Outside source interviews revealed staff were asked to review medications with outside source. During the review, the staff member accidentally pulled the medication for R2 and showed them to the outside source. The medication was not dispensed, only reviewed. The outside source confirmed no medications were dispensed or administered to either resident, as it was just a review. Staff also confirmed there were no medication errors involving either resident with the shared first name. Continued on an LIC 9099C.

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 08-AS-20230821160039

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: 10/20/2023

NARRATIVE

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Lastly, it was alleged staff did not meet resident’s medical needs. It was reported there was an order on file to check R1’s blood sugar levels and ensure R1 used their CPAP machine at night. However, the orders were not being followed. A review of R1’s Medication Administrator Record indicated R1 was receiving blood sugar checks as prescribed. The facility did not have an order on file for a CPAP machine for R1. Some staff interviews revealed not being aware of the CPAP machine and unable to assist with CPAP machine as they were not trained. Other staff observed the CPAP machine in R1’s room but never noted it in use or an order on file. Further staff interviews revealed there was a discussion with R1’s family that an order would be needed but they never brought the machine or order. R1’s records did not indicate the need or use for a CPAP machine.

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 are 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. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2]

SUPERVISOR'S NAME: Lizzette Tellez	TELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC9099 (FAS) - (06/04)

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