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

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 05/31/2024
Date Signed: 05/31/2024 11:31:15 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/30/2022 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220330150813
FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 157DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Tracy Knepple, Executive DirectorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Facility bathroom was not maintained cleaned
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegation. LPA identified herself and was granted entry by receptionist Stephanie Runyon. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Tracy Knepple.

The Department’s investigation consisted of interviews with residents and staff, records review of relevant documents pertinent to this investigation, and LPA observations. On March 30, 2022, it was alleged that the resident’s bathroom was not maintained cleaned.

It was alleged that the resident’s bathroom floor had splashes of urine and fecal matter. Interview with residents confirmed that they did not have issues with their bathroom being cleaned or being kept clean. During an interview with the Engineer, who oversees housekeeping, they said that the housekeeping staff has a current schedule posted for the staff on the designated areas they must clean for the day.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 7
Control Number 08-AS-20220330150813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 05/31/2024
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
They mentioned that they have a check sheet for the housekeeping staff to review while they clean to ensure the cleanliness of the areas. They also have implemented a survey for the residents to fill out as they want to hear from the residents. The Engineer has a monthly in-service training with staff to ensure they are properly cleaning and one of the current topics was the cleaning of resident’s rooms. Reviewed the in-service training sheet. According to the Housekeeping Team sheet, the topic of Resident Room Cleaning is done twice a year. It goes over how many times per week, the time frame it should take to clean and the number of units that should be cleaned per day. It also goes over the Room Assignment Schedule and the Housekeeping checklist, room cleaning and bathroom cleaning standards. On the back of the training is the Housekeeping Room Cleaning Checklist. Per the job description of the housekeeping position, and a part of their responsibilities is to maintain, clean and sanitize the bathrooms. During the initial visit on 4/05/2022, LPA toured the facility and observed multiple random rooms and their respective lavatories. LPA observed that they were all clean and there was no fecal matter or urine on their floors or around the toilets. During the subsequent visit on 05/28/2024, LPA observed that there were staff who were conducting their cleaning rounds throughout the facility.

Based on the Department’s investigation of the above-mentioned allegation and the evidence obtained during resident interviews and records reviewed, there is insufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegation is deemed to be unsubstantiated.

The report was discussed, and an exit interview was conducted with Executive Director Tracy Knepple. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) was provided to Executive Director Knepple at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 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
03/30/2022 and conducted by Evaluator Carmen Lopez
PUBLIC
COMPLAINT CONTROL NUMBER: 08-AS-20220330150813

FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 157DATE:
05/31/2024
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Tracy Knepple, Executive DirectorTIME COMPLETED:
11:40 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Residents alarm system was not operable
- Facility did not administer medication as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced complaint visit to deliver findings regarding the above-mentioned allegations. LPA identified herself and was granted entry by receptionist Stephanie Runyon. LPA stated the purpose of the visit and reviewed the findings of the complaint with Executive Director Tracy Knepple.

The Department’s investigation consisted of interviews with staff, residents and outside sources, records review of relevant documents pertinent to this investigation, and LPA observations. On March 30, 2022, it was said that the staff did not administer medications as prescribed, and resident’s alarm system was not operable.

It was said that the residents call button was not operational when they attempted to contact staff. Interview with the facility’s Engineer staff confirmed that the panel in the facility was sounding when the resident would pull their cord.
(Continuation on LIC9099-C)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20220330150813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 05/31/2024
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
(Continuation of LIC9099)
A tour of the panel was conducted, and they demonstrated what sounded on the panel and where the panel indicated the issue was. Engineer staff provided LPA with the room’s log to where the issue was located. In review of the log, the description verified that the smoke alarm was being triggered each time that the resident would call for staff assistance. In review of the invoice for the services that were performed, it demonstrated that the panels wires had a ground fault and repairs were made to the nurse switches to that specific room. Based on the information obtained, there is sufficient evidence to support this allegation.

It was said that the staff provided resident #1 (R1s) medication daily when their primary care physician (PCP) had discontinued a medication from a daily medication to a pro re nata (PRN). In review of the facility’s Medication Administration Record (MAR) the medication that which was incorporated as a routine medication order was dated March 15, 2022. According to the routine medication order, the medication was discontinued on March 26, 2022. In review of the same month’s PRN medication orders listed the same medication on R1’s MAR as a PRN and provided to R1 as a PRN for the dates of March 15 – 19, 22, 27 – 29, and 31, 2022. According to the Discontinuation Orders, this medication was discontinued twice. The first on 3/04/2022, but the MAR indicated that it was not due. The second time this medication was discontinued was on 03/25/2022, which MAR shows an X for not due. This medication was issued in March 2022 as R1's MAR for December 2021, January 2022, and February 2022 did not have an order for this medication. According to the primary care physician's (PCPs) order there was an order change for this medication on 03/24/2022 from taking one tablet in the morning to taking one tablet every eight hours as needed. This was reflected on the MARs routine med order, and not to exceed 4 grams per day from all sources. This medication reflected on the PRN medications list as being administered a second time that started March 15, 2022, but did not exceed the dosage allowed.

In further review of R1s, MAR, there was one other medication that was incorrectly discontinued. The medication was discontinued prior to the discontinuation date. The medication was not administered on 3/03/22 – 03/05/22 and was marked as discontinued on 3/05/2024 on the MAR. According to the annotation on the order it showed that the discontinuation date was on 3/04/2022. According to the Discontinuation orders, the discontinuation date is 03/04/2022.

It was additionally said that the medications were being provide incorrectly to residents and there were medications that were missed for residents on/or around September 2022. In review of randomly selected residents MARs for September 2022 they indicated that there were discrepancies that the facility annotated for many medications unable to verify the medications and the medications were not administered. Although there were no annotations indicating the incorrect medications were provided to a resident on the MAR, there is information regarding the medications that were missed.
(Continuation on LIC9099-C)
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20220330150813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 05/31/2024
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
(Continuation of LIC9099-C)

According to R1s MAR, it showed that there were 11 medications that were not administered in September 2022 and in the back of the MAR it shows that staff did not administer mainly due to unable to verify. In review of resident #2 (R2) records for September 2022, there were four medications that were not administered due to unable to verify. In review of the records for resident #3 (R3), there were three medications and one essential oil that were not administered from the routine medication order due to unable to verify. In review of resident #4’s (R4) MAR for September 2022, they did not administer 10 medications on multiple days throughout the month due to mainly refusal or unable to verify. In review of the resident #4’s (R4) MAR it reflects that there were 11 medications that were not administered and according to the notes in the back was due to unable to verify.

Upon further review of the MARs for the five residents during the month of March 2023 residents had multiple medications that were not administered due to inability to verify, blank notes, inability to locate, and pending refill or PCP approval for over half of one month’s worth of medications.

Lastly, it was said that the medications were not being administered on time for residents who are insulin dependent and for pain management. Upon review of the current residents, R1, R2, R3, R4, and R5 they all had regular diets and no diagnosis of being insulin dependent. In review of the MAR’s they do not have timeframes the medications are administered unless they are a PRN. According to R4’s MAR they missed one of their medications due to inability of the facility to obtain the medication timely. At the beginning of the month, the medication was pending refill. Then the medication was later pending authorization, then the medication showed as being held towards the end of the month by the PCP which went back and forth. At the end of the month the footnote would indicate that the medication was refused, or the medication could not be verified.

Interview with outside source statements conflicted. An outside source did not recall their time at the facility. Another outside source said that they did not recall any missed medications or medications not being provided to residents as prescribed by their PCP but recalled that the facility had outside agencies assisting as there was not enough staff. Another outside source and staff mentioned that they did not recall any medications not being provided to a resident as prescribed.

(Continuation on LIC9099-C)
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 08-AS-20220330150813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 05/31/2024
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
(Continuation on LIC9099-C)

There were staff who confirmed there had been medication errors and one that occurred about one year ago. According to staff interviewed the medication errors are reported to the charge nurse who then is responsible to ensure that the resident is monitored for 72 hours and responsible to make the proper notifications. Residents said that they walk to the Wellness Center for their AM and PM medications and the night medications are taken to their rooms. Executive Director confirmed that night medications are taken to the residents. Based on the information obtained there is sufficient evidence to support the allegation.

Based on the Department’s investigation of the above-mentioned allegations and the evidence obtained during staff, resident and outside sources interviews, and review of pertinent records, there is sufficient evidence to meet the preponderance of evidence standard. Therefore, the above allegations are deemed to be substantiated. California Code of Regulations, Title 22, Division 6, Chapter 8, is being cited on the attached LIC9099-D.

The report was discussed, plan of correction was jointly developed, and an exit interview was conducted with Executive Director Tracy Knepple. A copy of this report along with Licensee/Appeal Rights (LIC9058 01/16) were provided to Executive Director Tracy Knepple at the conclusion of the visit. The signature below confirms the documents were received.
SUPERVISOR'S NAME: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20220330150813
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/31/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/28/2024
Section Cited
CCR
87465(d)
1
2
3
4
5
6
7
87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration… this requirement was not met as evidenced by:
1
2
3
4
5
6
7
Director of Resident Care Services will provide in-service training to med techs and nursing staff regarding proper medication administration and follow-up on pending orders and submit in-service training sheets to LPA by POC due date, 06/28/2024.
8
9
10
11
12
13
14
Based on interviews and records review, the staff did not assist R1 with self-administration of a medications as prescribed. This posed a potential health risk to 5 of 150 of residents in care.
8
9
10
11
12
13
14
Type B
06/14/2024
Section Cited
CCR
87303(i)(1)(B)
1
2
3
4
5
6
7
87303 Maintenance and Operation (i)(1)(B) Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff… this requirement was not met as evidenced by:
1
2
3
4
5
6
7
Cleared on site as the signal system was fixed in 2022.
8
9
10
11
12
13
14
Based on interviews, records review and LPA observations, the facility did not comply with the section cited above as the residents call signal was inoperable which posed a potential safety risk to 1 of 150 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: Jennifer LottTELEPHONE: (619) -34-3976
LICENSING EVALUATOR NAME: Carmen LopezTELEPHONE: (619) 314-0757
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7