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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 06/07/2024
Date Signed: 06/07/2024 12:05:44 PM


Document Has Been Signed on 06/07/2024 12:05 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: 158DATE:
06/07/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Director of Residential Care Services- Keisha BeanTIME COMPLETED:
12:15 PM
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
Licensing Program Manager (LPM) Simon Jacob arrived on June 7, 2024 for an unannounced case management visit to follow up on a substantiated complaint investigation. LPM Simon Jacob met with Director of Resident Care Services, Keisha Bean, and reviewed the report.

On May 6, 2021, the Department concluded a complaint investigation which alleged that a resident sustained multiple pressure injuries resulting in hospitalization due to staff neglect. The allegation was substantiated, and the licensee was cited under California Code of Regulations § 87465(g) – Incidental Medical and Dental Care, which states in part, “The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...” On August 24, 2021, the licensee was also cited, on case management, three violations as a result of the complaint. The first deficiency was cited under California Code of Regulations, Title 22 § 87609(b)(2), Allowable Health Conditions and the Use of Home Health Agencies, which states in part, “Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.” The second deficiency was cited under California Code of Regulations, Title 22 § 87411(a) Personnel Requirements – General, which states in part, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” The third deficiency was cited under California Code of Regulations, Title 22 § 87616(a), Exceptions for Health Conditions, which states in part, “As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.”

At the time of the complaint visit on June 23, 2022, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49.
SUPERVISOR'S NAME: Kimberly LyonTELEPHONE: (619) 767-2300
LICENSING EVALUATOR NAME: Simon JacobTELEPHONE: (619) 767-2306)
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2024
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 2


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: 06/07/2024
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
The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.

This is evidenced by the licensee’s failure to contact 9-1-1 or obtain emergency medical services when they observed an imminent threat to the health of the resident, failure to obtain a written plan of care from the home health agency and mobile wound care provider for the new and ongoing pressure injuries, failure to conduct a reappraisal, failure to train and supervise facility staff responsible for providing supporting care and supervision, and for failure to ensure staff followed physician’s orders which contributed to the development of the pressure injuries and infection that emitted foul odors and required medical intervention, including hospitalization and maggot debridement therapy.

Today, June 7, 2024, the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injuries in the amount of $10,000. However, since an immediate civil penalty of $500 was previously assessed on June 23, 2022, the amount of the civil penalty issued today will be $9,500.

A copy of the LIC 421D was given to Director of Resident Care Services, Keisha Bean and originals were signed.

An exit interview was conducted, a copy of the report was issued, and Appeal Rights were provided. Director of Resident Care Services, Keisha Bean's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421D.
SUPERVISOR'S NAME: Kimberly LyonTELEPHONE: (619) 767-2300
LICENSING EVALUATOR NAME: Simon JacobTELEPHONE: (619) 767-2306)
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2