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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 06/27/2024
Date Signed: 06/27/2024 04:54:46 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/02/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240202133159
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: 163DATE:
06/27/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Director of
Resident Care Service, Keisha Bean		TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Licensee did not ensure food is of good quality
Licensee did not ensure resident records are current
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Director of Resident Care Service, Keisha Bean.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the licensee did not ensure food is of good quality by serving burnt, overcooked and undercooked food. The food is cooked and prepared in the main kitchen then delivered to memory care. The breakfast was observed on multiple occasions by staff being of poor quality and returned to the main kitchen. Staff interviews confirmed the bacon was burnt, eggs were watery and green, and the pancakes were powdery. Further staff interviews revealed the main kitchen complains that too much food is being sent back. The main kitchen also sends over hard meat and veggies that are not cooked, which those are hard for residents to eat. Continued on an LIC 9099C.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
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 6
Control Number 08-AS-20240202133159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/27/2024
NARRATIVE
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Staff also reported they can return the food items and request better quality. Executive Director’s interview revealed they recently had to hire a new cook due to unforeseen circumstances. However, ED has not heard of food complaints and believes the cook is doing a good job.

It was also alleged the licensee did not ensure resident records are current. Title 22 Regulations require residents with a diagnosis of a Major Neurocognitive Disorder have an annual medical assessment. A review of records indicated Resident #1 (R1) and Resident #2 (R2) both have a Major Neurocognitive Disorder did not have current medical assessments. R1’s Physician’s Report was dated 08/18/22 and R2’s Physician’s Report was dated 07/12/21. The Physician’s Reports were collected on 02/09/24.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care Service, Keisha Bean 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: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 08-AS-20240202133159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/18/2024
Section Cited
CCR
87555(a)
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General Food Service Requirements. The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents...the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.
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Director of Resident Care Services stated the facility will implement a policy along wth training to ensure the kitchen lead inspects and verifies food is of good quality prior to sending to memory care. Proof of policy and training due by POC due date.
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This requirement is not met as evidenced by: Based on interviews, the licensee did not ensure good quality of food for 21 of 147 [R1-R21] residents, which poses a potential health and safety risk to residents in care.
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Type B
07/18/2024
Section Cited
CCR
87705(c)(5)
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Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: Each resident...shall have an annual medical assessment...of the resident’s dementia care needs. This requirement is not met as evidenced by:
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Director of Resident Care Services stated they will provide a current Medical Assessment for residents #1 and #2 by POC due date.
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Based on record review the licensee did not ensure medical assessments were current for 2 out of 147 [R1-R2], residents, which poses a potential health and safety risk to residents in care.
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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: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/02/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240202133159

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: 163DATE:
06/27/2024
UNANNOUNCEDTIME BEGAN:
01:40 PM
MET WITH:Director of
Resident Care, Keisha Bean		TIME COMPLETED:
02:45 PM
ALLEGATION(S):
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Staff handled residents in a rough manner
Staff did not ensure residents are free from punishment
Staff did not treat residents with dignity
Staff did not allow residents to use their own personal possessions
Staff did not ensure residents hygiene needs are met
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced visit to conclude the complaint investigation regarding the above mentioned allegations. LPA met with Director of Resident Care, Keisha Bean.

During the investigation, the facility was briefly toured, records reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff handled residents in a rough manner. It was reported Resident #1 (R1) was being manhandled. Staff interviews revealed residents are not handled in a rough manner and they have not observed any physical abuse. Resident interviews confirmed they are not being handled in a rough manner. Interviews conducted with resident family members confirmed residents are not being handled in a rough manner.

It was also alleged staff did not ensure residents are free from punishment. It was reported Resident # 2 (R2) was denied water; Resident #3 (R3) was being kept from going to their room; and Resident #4 (R4) was being denied bathroom use. Continued on an LIC 9099C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 08-AS-20240202133159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/27/2024
NARRATIVE
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Outside sources reported staff were using thickener powder for R2’s water due to R2 repeatedly requesting water. Staff interviews revealed R2 tends to repeatedly ask for water due to their medical condition. Further staff interviews confirmed R2 was provided water when requested but also monitor R2’s water consumption for safety. Staff also stated a prescription was needed for thickener power, which R2 does not have. Staff denied using thickener powder. On 02/09/24, LPA observed R2 repeatedly requesting water and receiving it. R2’s interview confirmed they are being provided water upon request. It was reported R3 was being kept from going to their room. Staff interviews stated residents are encouraged to participate in activities and they prefer residents in the common areas. However, residents can go to their room any time.

All residents are provided with a key to their room. The resident rooms lock automatically to prevent wandering residents. The residents have a Major Neurocognitive Disorder and are assisted to their rooms by staff or can independently go to their room. R3’s interview confirmed they are not being kept from going to their room. On 02/09/24, LPA observed R3 requesting to go to their room and staff assisted. It was also reported R4 was being denied bathroom use. Staff interviews revealed R4 has a medical condition that makes R4 believe they have to frequently use the bathroom. Staff interviews also revealed the facility was working with R4’s family regarding the urgency to use the bathroom. On 02/09/24, LPA observed R4 request an escort to use the bathroom. Staff assisted R4 to their bedroom to use the bathroom. Once R4 was done and returned to the common area, they immediately asked to use the bathroom and commented they never used the bathroom. R4’s interview confirmed they can use the bathroom whenever they like.

It was also alleged staff did not treat residents with dignity. It was reported R1 was called an inappropriate word by staff and told hurtful things about R1’s family members. Also, R3 will repeatedly ask the same question due to their Major Neurocognitive Disorder and told by staff that their parents were dead, each time R3 asks for them. Resident interviews revealed denial of being called inappropriate words or being told anything negative about their families. Staff interviews confirmed they are not using inappropriate words or negative comments towards residents.

It was also alleged staff did not allow residents to use their own personal possessions. It was reported Resident #5 (R5) was denied the use of their eyeglasses. Continued on an LIC 9099C

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 08-AS-20240202133159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/27/2024
NARRATIVE
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Staff interviews revealed R5 has many pairs of eyeglasses and will set them down in different places due to their forgetfulness. Therefore, the family bought R5 multiple pairs. The eyeglasses are not prescribed by a physician, but store-bought reading glasses. On 02/09/24, LPA observed R5 was wearing a pair of glasses and had a pair hanging from the middle of their sweater. R5’s interview revealed they always have access to their eyeglasses. It was also reported Resident #6 (R6) was being denied access to their hearing aids. Staff reported R6’s hearing aids are kept at the desk of the Director of Memory Care for safety and charging. Staff’s interview confirmed they are aware of the process for R6’s hearing aids. Outside source interviews confirmed staff charge R6’s hearing aids then bring them for R6 daily. Outside sources also stated there were times the hearing aids were not charged. However, R6 was never denied the use of them. On 02/09/24, LPA observed R6 was wearing charged hearing aids.

It was also alleged staff did not meet residents’ hygiene needs by not showering and changing residents’ clothing for days. Staff interviews revealed residents are showered according to their shower schedule and clothing is changed daily. Outside source interviews revealed R5 has worn the same clothing for two to three days consecutively. Staff interviews stated R5 has trouble seeing and will usually spill food on their clothing. However, R5’s clothing is changed daily. Additional outside sources revealed R6 was observed in the same clothing for three days consecutively. However, it was a one-time occurrence. On 02/09/24, LPA observed R5 had food spilled on their clothing, staff confirmed R5 just had lunch. LPA also observed R6, who was clean and dressed well. LPA has observed R6 on multiple occasions while visiting the facility and R6 was kept clean. Residents are being showered accordingly and clothing changed daily. Resident interviews confirmed they are being showered and clothing changed daily.

During the course of the investigation, interviews were conducted, and records were reviewed. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegations. The allegations are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care, Keisha Bean whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Residents 1-6]

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 06/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/27/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 6