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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 02/29/2024
Date Signed: 02/29/2024 05:19:31 PM


Document Has Been Signed on 02/29/2024 05:19 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: 152DATE:
02/29/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director Tracy Knepple and Director of Resident Care Keisha BeanTIME COMPLETED:
05:30 PM
NARRATIVE
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LPA Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management – Incident 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 Keisha Bean.

Today's visit was in response to an LIC624 Incident Report, which licensee self-submitted to the CCLD San Diego Regional Office (received on 02/15/2024). According to the LIC624: during the morning of 02/07/2024, an error by Staff #1 (S1) led to Resident #1 (R1) receiving doses of multiple medications which were not prescribed to them. These medications were instead prescribed to Resident #2 (R2). [See LIC 811 Confidential Names List for a description of select person identifiers used in this report].

During today’s visit, LPA performed a brief facility tour and welfare check on R1, verifying that they were safe. LPA collected copies of and reviewed pertinent care records, training records, and physician correspondence. LPA also interviewed relevant staff.

According to their latest LIC602 Physician’s Report (dated 06/30/2022), R1 was diagnosed with Mild Cognitive Impairment (MCI) and required staff assistance with taking their prescribed medications. Due to their baseline memory loss, R1 confirmed they felt well today, but was unable to recall the incident.

Staff interviews aligned to show: On the morning of 02/07/2024, S1 was a newer employee undergoing medication pass training with a nurse manager. The nurse manager briefly stepped away to tend to another resident. Around 9:00 AM, Staff #2 (S2) had prepared a cup with medications for R2 and labeled it with R2’s name. S1 sought to assist S2 with their duties but confused/mistook R1 for R2. S1 did not ask R1 to verify their identity, and incorrectly handed this cup of pills to them. R1 then ingested four (4) medications which were not prescribed to them. Staff quickly recognized the error and timely notified R1’s primary care physician (PCP). [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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
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: 02/29/2024
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[CONTINUED FROM LIC 809]

Interviews, corroborated by faxed correspondence and date and timestamped progress notes, showed: The PCP provided written orders for staff to continue to monitor R1 at the facility and specified the circumstances / symptom triggers under which R1 would need to be sent to the hospital. R1 vomited later that same morning after eating a meal, but said they felt better after. R1 did not experience changes in their breathing or mentation. R1 did not exhibit the symptom triggers specified by the PCP to warrant 911. Staff measured R1’s blood pressure multiple times, finding it was consistently within a safe range. Staff continued to closely observe R1 for the remainder of the day and R1 returned to their baseline condition without the need for hospital treatment.

Per manager interview and R2’s Medication Administration Record (MAR), the medication errors which affected R1 on morning of 02/07/2024 did not prevent R2 from receiving their respective prescribed medications on that date.

Personnel records showed that Licensee provided one-on-one remedial medication pass training to S1 following the incident.

A preponderance of evidence exists to show: During the incident in question, License’s staff (S1) did not give R1 medications as they were prescribed. The incident caused R1 to vomit but did not result in serious illness to R1. One (1) deficiency was cited per California Code of Regulations, Title 22 (refer to the attached LIC 809-D). A Plan of Correction was jointly developed with the Licensee. LPA also issued one (1) Technical Violation (TV) regarding reporting requirements.

An exit interview was conducted with Knepple and Bean, to whom a copy of this report, the LIC 809-D, the LIC9102-TV, the LIC811 Confidential Names List, 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: 02/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/29/2024 05:19 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: 02/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/29/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care: “(a)(4) The licensee shall assist residents with self-administered medications as needed.” This requirement was not met, as evidenced by:
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Manager interview and personnel records showed: On 02/20/2024, facility management met with S1 to perform remedial training regarding medication assistance. Licensee agreed to also perform retraining with its larger LVN/Med Tech team on medication pass procedures, and to submit the training sign-in sheet to LPA, by the POC due date.
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Based on records and interviews, Licensee’s staff did not assist 1 of 152 residents (R1) with self-administered medications as needed/prescribed, which posed a potential health risk to persons 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.
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Dang NguyenTELEPHONE: (619) 210-9024
LICENSING EVALUATOR SIGNATURE:
DATE: 02/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/29/2024
LIC809 (FAS) - (06/04)
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