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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 07/16/2024
Date Signed: 07/17/2024 08:18:31 AM


Document Has Been Signed on 07/17/2024 08:18 AM - 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: 159DATE:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with with Executive Director, Tracy Knepple.

Today, the facility was briefly toured, records requested and interviews conducted with staff and resident. The facility self reported an incident regarding Resident #1 (R1). On 07/12/24, R1 was witnessed falling from the third floor balcony of the facility. The facility acted appropriately and contacted 911, R1 was transported to hospital for further medical evaluation. R1 passed away at the hospital the same day.
No deficiencies were issued today. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].
SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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