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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 08:17:08 AM


Document Has Been Signed on 07/17/2024 08:17 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:
03:31 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
06:30 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.

The facility self reported an incident regarding Resident #1 (R1). On 07/07/24, the facility's Licensed Vocational Nurse (LVN) was witnessed being rude and not treating R1 with dignity. R1 was receiving hospice services and it was not safe for R1 to get up from bed. R1 also has a private companion hired by the family. The LVN raised their voice at facility staff in front of R1 and R1's private companion regarding not being allowed to get up from bed. The ED stated they honor resident's wishes regardless of their physical state. The LVN also made inappropriate comment towards R1, by referring to R1 as a child. The Executive Director's interview confirmed that it is the expectation to honor resident's wishes, including requesting to use restroom or to get out of bed, even if there may be difficulty or obstacles.

The facility also self reported another incident regarding Resident #1 (R1). The facility provides medication management for R1. On 07/08/24, the Medication Technician documented R1 refused their medications. R1's family stated that they had video coverage of the room and no one entered or attempted to provide R1 with medications. The Medication Technician falsified the Medication Administration Record and documented R1 refused the medications. R1 did not receive their medications during the AM shift. The facility was proactive and conducted In-Service training for all staff members who are involved with medication administration.

The Executive Director stated action was taken immediately once made aware of the incident to ensure the two staff were no longer involved with resident care. The LVN and the Medication Technician were terminated.

Deficiencies were cited today on the attached LIC 809D. 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)
Page: 1 of 2


Document Has Been Signed on 07/17/2024 08:17 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/13/2024
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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The Executive Director provided proof of medication training that was conducted on 07/12/24, POC cleared.
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Based on interviews and record review the licensee did not ensure 1 out of 159 [R1] residents received medications as prescribed, which was a potential health and safety risk to residents in care.
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Type B
08/13/2024
Section Cited
CCR87468.1(a)(1)

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Personal Rights of Residents in All Facilities. To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement is not met as evidenced by:
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The Executive Director stated Personal Rights training will be conducted and proof of training will be provided by POC due date.
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Based on interviews and record review the licensee did not ensure 1 out of 159 [R1] residents were not treated with dignity which was 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: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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