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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 10/05/2021
Date Signed: 10/06/2021 08:55:06 AM

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:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 129DATE:
10/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Executive Director, Inan LintonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA identified herself and discussed the purpose of the visit with Executive Director, Inan Linton and Director of Care Services, Amy Salvador.

During today’s visit, LPA interviewed staff and obtained records. On 10/04/21, Community Care Licensing received a self reported incident report and a death report. The incident involved Resident #1 (R1) being found on the floor on 09/22/21 and sustained injury. The death report involved Resident #2 (R2), on 09/20/21, R2 had a fall and hit their head and was transported to the hospital, where they later passed. No deficiencies were issued today.

An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Executive Director via electronic mail. An electronic mail read receipt was requested to be provided upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2].
SUPERVISOR'S NAME: John RanteTELEPHONE: (619) 994-7269
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 10/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2021
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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