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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 06/20/2024
Date Signed: 06/20/2024 02:11:25 PM


Document Has Been Signed on 06/20/2024 02:11 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
SAN DIEGO RO, 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: 157DATE:
06/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Keisha Bean, Director of
Resident Care
TIME COMPLETED:
02:20 PM
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LPA Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Resident Care Keisha Bean.

Today's visit was in response to an LIC 624 Incident Report, which licensee self submitted to the CCLD San Diego Regional Office (received on 06/17/2024). According to the LIC 624: during the morning of 06/11/2024, Resident 1 (R1) exited the facility and walked along the street out front of the facility. R1 was picked up by the facility driver and was returned safely to the community. R1 was assessed by staff with no injuries noted and also met with staff to discuss their reason for leaving. After speaking with the resident, R1 expressed an understanding of not leaving the facility unassisted again and that if they want to leave they will seek assistance.

During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent records. LPA also interviewed relevant staff.

According to their latest LIC 602 Physician’s Report (dated 01/29/2024), R1 was diagnosed with Mild Cognitive Impairment (MCI) and required staff assistance with taking their prescribed medications and it is documented that the resident is not able to leave the facility unassisted.

An exit interview was conducted with Bean, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

SUPERVISOR'S NAME: Denise PowellTELEPHONE: (619) 301-9770
LICENSING EVALUATOR NAME: Tiffany HolmesTELEPHONE: (619) 481-0843
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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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