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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 03/28/2024
Date Signed: 03/28/2024 05:45:35 PM


Document Has Been Signed on 03/28/2024 05:45 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: 151DATE:
03/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:46 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management- Incident visit. LPa met with Executive Director, Tracy Knepple and discussed the purpose of the visit.

The facility reported a timely incident involving Resident #1 (R1) that occurred on 03/09/24. The report indicated Staff #1 (S1) allegedly abused R1. S1 was suspended for approximately 1 (one) week pending the facility's investigation. R1 has a Major Neurocognitive Disorder and was unable to recall the incident. The facility assessed the resident and no injuries were sustained. The facility followed protocols and no deficiencies were issued. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) 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: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2024
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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