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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 05:03:07 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
12/08/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221208115812
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:
03:50 PM
MET WITH:Director of Resident Care Service, Keisha BeanTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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Staff do not respond timely to residents’ calls for assistance
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 staff do not respond timely to residents’ calls for assistance. LPA reviewed the facility’s log of resident requests for assistance initiated via individually assigned pendants. The review of requests that were initiated on November 1, 2022, through December 15, 2022, revealed that in response to five (5) resident requests initiated via pendant, had response times from (1) minute to one (1) hour and forty (40) minutes. There were multiple occasions where more than thirty (30) minutes elapsed before resident pendants were restored. Based upon a review of records maintained by or on behalf of the facility, on that date, wait times were unreasonably long, and resident requests for assistance were not responded to in a timely manner. 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-20221208115812
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 revealed sometimes it take a long time for staff to respond but they understand they are assisting other residents. The Executive Director’s (ED) interview revealed there is one (1) caregiver per twenty-four (24) residents, which is two (2) hallways- 2nd floor. However, the second floor has independent residents and residents that require assistance. The facility also has a floater staff, and they utilize a staffing agency daily. The ED also stated It's not typical for the staffing agency to cover the hallway on their own. They will move staff around to assist, such as the floater or from another floor because the staff from the agency understand basic care giving but not necessarily the resident's routine. Outside source interviews revealed a family member was visiting a resident and staff were not responding, which was over 30 minutes. Therefore, the family member had to search for a staff member to assist. Additional outside sources indicated some residents are full assist which can take one (1) hour for resident’s tasks so it's difficult for staff to get to everyone timely.

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-20221208115812
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
87411(a)
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Personnel Requirements – General. Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement was not met as evidenced by:
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Director of Resident Care Service stated they are in the process of implementing a new policy regarding decreased response time. The facility is purchasing new staff communication equipment and providing training on the new policy. The facility will
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Based on record review, the licensee did not respond to 5 out of 161 [R1-R5] residents’ requests for assistance in a timely manner. Some resident wait times were more than 30 minutes for staff to respond to and restore pendants. This poses a potential health and safety risk to residents in care.
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submit new policy by POC due date and provide proof of training once completed.
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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
12/08/2022 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20221208115812

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:
03:50 PM
MET WITH:Director of Resident Care Service, Keisha BeanTIME COMPLETED:
05:10 PM
ALLEGATION(S):
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-Staff leave residents in wet and soiled diapers for extended periods
-Staff did not provide breakfast to residents
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 staff leave residents in wet and soiled diapers for extended periods. The facility does not document changing of incontinent products. Staff interviews revealed residents with incontinence care are changed on a regular basis. Staff toilet or change diapers for residents with incontinent care before and after each meal. In addition, each shift, staff are assisting residents with incontinent care. Resident interviews revealed they were not left in wet or soiled diapers for extended periods. The Executive Director’s interview indicated the PM shift changes the resident two – three (2-3) times. 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-20221208115812
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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Then the NOC shift comes in and they do shift turnover and state who needs to be changed or was just changed. ED said staff communicate well during shift turnover. Therefore, residents are not left in wet and soiled diapers.

It was also alleged staff did not provide breakfast to residents. It was reported staff are not able to get all the residents up in time for breakfast. Therefore, residents are missing their breakfast. Resident interviews revealed they eat in the dining room and not have missed breakfast due to staff. Staff interviews revealed all residents eat in the dining room or have tray service. Staff stated residents have the right to refuse breakfast, but residents are not missing breakfast due to staff neglect. The ED’s interview revealed the facility does not document missed breakfast because the resident has the right to refuse. If the resident misses two consecutive breakfasts, then it's documented and addressed. There was no documentation indicating breakfast was missed consecutively, as residents were eating.

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