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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 04:57:03 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
05/07/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240507100826
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:
02:46 PM
MET WITH:Director of Resident Care Service, Keisha Bean. TIME COMPLETED:
03:49 PM
ALLEGATION(S):
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Residents are not receiving medications
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 allegation. 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 residents are not receiving medications. It was reported multiple residents were not receiving their medications and are given incorrect medications. Staff interviews revealed residents are given their correct medications and there are no medication errors. Resident interviews reflected they believed they were given correct medications but could not be certain. A review of multiple Medication Administrator Records (MARs) for April 2024 reflected medications dispensed and medications not dispensed for various reasons. The MARs have a symbol key indicator, which is documented for the dates the medications were not dispensed or given and initialed by staff. 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 5
Control Number 08-AS-20240507100826
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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The key indicator had multiple symbols, to include a symbol for “missed dose” and a symbol for “not administered - see notes.” The MARs also have a notes page to reflect the reason the medication was not dispensed. A review of the notes page indicated there were multiple missed doses and as well as not administered. However, no reasons were documented for multiple medications for multiple residents, which confirmed residents are not receiving medications as prescribed. Due to the facility not documenting the reason medications were not dispensed, only that they were not dispensed, confirmed residents weren’t given their prescribed medications. In addition, the MARs reflected not applying a prescribed ointment/cream because staff could not locate it for multiple days. The facility did not ensure residents were receiving all their prescribed medications. There were no reported adverse results from missed and/or not administered medications.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8 is 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: 2 of 5
Control Number 08-AS-20240507100826
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
87465(a)(4)
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Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Director of Resident Care Service stated staff will attend vendor training regarding medication administration and documentation by POC due date.
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Based on record review the licensee did not ensure medications were given as prescribed to 4 out of 151 [R1-R4] persons in care which could pose 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: 3 of 5
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
05/07/2024 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20240507100826

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:
02:46 PM
MET WITH:Director of Resident Care Service, Keisha BeanTIME COMPLETED:
03:49 PM
ALLEGATION(S):
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-Residents are not being checked on by staff
-Staff are not properly trained on transferring residents
-Residents pendants are in disrepair
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 residents are not being checked on by staff. It was reported staff not are not checking on residents every two (2) hours. The Executive Director’s (ED) interview revealed there was no set time frame to check on residents. However, staff check residents’ multiple times during their shift and ensure residents needs are met. Staff interviews confirmed they are checking on residents’ multiple times during their shift. Staff stated residents with incontinent care are checked more often for toileting. Staff also explained residents that are incontinent are checked before and after each meal, which is in addition to regular checks. 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: 4 of 5
Control Number 08-AS-20240507100826
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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Resident interviews confirmed they are being checked on regularly. However, some residents admitted they don’t like being checked on, yet staff continue to regularly check for their safety.

It was also alleged staff are not properly trained on transferring residents. Outside source interviews reported staff are not transferring residents correctly with person to person and transfers, as well as transfers with the use of a hoyer lift. The Executive Director’s interview revealed all staff are provided training with all transfers. The ED submitted proof of training for staff regarding transfers. The ED also explained new staff are paired with an existing staff to assist with transfers, to ensure new staff are comfortable with transfers. Staff interviews confirmed they receive training on transfers. Staff also stated they are paired with a staff that has experience. Additional staff interviews confirmed new staff will stay with the experienced staff until they are ready to independently work with the residents that require transfers. Staff also stated there is no set time frame, some staff need three shifts with the experienced staff and some new staff may need a month. The ED allows as much time as needed to ensure staff transfers are done correctly and safely. Resident interviews confirmed staff are transferring them appropriately and had no concerns.

Lastly, it was alleged resident’s pendants are in disrepair. It was reported over fifteen (15) pendants were in disrepair. On 05/15/24, LPA interviewed and observed multiple residents and their pendants, none were in disrepair. In addition, all resident rooms have a pull cord in the event of emergency. Also, not all residents are issued pendants, as it based on the level of care provided to the resident. Outside source interviews revealed some resident’s pendant were inoperable. However, some of those reported residents were not issued pendants. Staff interviews revealed sometimes a resident’s pendant will not be working and they take it to concierge and put a work order in. Staff verified the pendant is fixed within twenty-four (24) hours. Additional staff stated if the pendant isn’t working, they take it directly to maintenance and it’s repaired on the spot immediately. The ED and staff stated the issue is usually the battery is low, which is repaired quickly. Outside source interviews revealed a resident’s pendant was inoperable and the facility fixed it within 24 hours. In addition, the outside source stated staff set up the resident’s pull cord in their room in a way the resident would have easy access, while waiting for the repair.

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 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 5