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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 08/28/2024
Date Signed: 08/29/2024 07:55:14 AM


Document Has Been Signed on 08/29/2024 07:55 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: 156DATE:
08/28/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:06 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management visit - Other. LPA met with Executive Director, Tracy Knepple.

Today, LPA was at the facility for an investigation. During the resident interviewing process. LPA observed Resident #1 (R1) sitting in the common area near their apartment. LPA approached R1 and they stated they were not feeling well and had Covid-19. R1 also had their apartment door open, allowing exposure. The facility did not follow their infection control guidelines by ensuring the resident was isolated. The Executive Director was made aware of R1 sitting in the common area. The ED requested R1 to return to their apartment and explained keeping other residents safe. The ED also stated she will have staff conduct rounds to ensure Covid-19 positive residents are isolated per infection control guidelines.

A deficiency was issued and 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 Executive Director, Tracy Knepple 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: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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Document Has Been Signed on 08/29/2024 07:55 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: 08/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/04/2024
Section Cited
CCR
87470(b)(3)

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Infection Control Requirements. There shall be separation and care of residents whose illness requires separation, including quarantine or isolation, from others. This requirement is not met as evidenced by:
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Executive Director stated staff will be trained on infection control requirements. Proof of training will be submitted by POC due date.
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Based on observations and interviews, the licensee did not ensure Covid positive residents are isolated for 1 out of 156 residents [R1], 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: 08/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
LIC809 (FAS) - (06/04)
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