374603279-1-30-2025-08-AS-NPED-DDF59U-20250130184607

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 01/30/2025
Date Signed: 01/30/2025 06:46:33 PM

Document Has Been Signed on 01/30/2025 06:46 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME:	BELMONT VILLAGE SABRE SPRINGS		FACILITY NUMBER:	374603279
ADMINISTRATOR/ DIRECTOR:	TRACY KNEPPLE		FACILITY TYPE:	740
ADDRESS:	13075 EVENING CREEK DR S		TELEPHONE:	(858) 486-5020
CITY:	SAN DIEGO	STATE: CA	ZIP CODE:	92128
CAPACITY: 184		CENSUS: 154	DATE:	01/30/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	04:15 PM
MET WITH:	Executive Director, Tacy Knepple		TIME VISIT/ INSPECTION COMPLETED:	05:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management – Other visit. LPA met with Executive Director, Tacy Knepple and discussed the purpose of the visit. The facility self reported an incident regarding Resident #1 (R1). On July 7, 2024, R1 was witnessed falling from the third floor balcony of the facility. The facility contacted 911 immediately after discovering R1. R1 was transported to hospital for further medical evaluation. On July 12, 2024, the resident passed away at the hospital. During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. R1’s Preplacement Appraisal dated July 24, 2023, indicated R1 had a Major Neurocognitive Disorder, was very impulsive, and lacked awareness of objects/obstacles close by. The appraisal did not reflect suicidal ideations. R1’s Physician Report dated October 19, 2023, indicated R1 was ambulatory, confused, depressed, unable to communicate needs, and required assistance with bathing, dressing/grooming, and toileting. R1 resided in the Assisted Living (AL) portion of the facility. The facility documented the Major Neurocognitive Disorder and determined R1 was safe and did not require their secured memory care unit. Based on the facility’s assessments, R1 did not have exit seeking behaviors. In addition, R1’s family member’s interview revealed they did not want R1 in the secured memory care unit, as R1 was doing well and progressing with the program. R1 was part of a program called Circle of Friends at the facility. The program was designed as a bridge from AL to memory care. Residents have the ability to attend the program and live in AL, while attending activities to assist with continued independence. Once the resident is no longer able to attend the program due to increased confusion/memory loss or exit seeking behavior, they may transition into the memory care unit. Circle of Friends is located on the third floor of the building, with balcony access. Staff interviews confirmed they were not aware of any suicidal ideations. A review of resident records did not reflect any suicidal ideations but indicated depression. Continued on an LIC 809C.

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
	VISIT DATE: 01/30/2025

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R1 was receiving medical treatment and medication for the depression. Outside source interview revealed R1’s family member was aware R1 was having difficulty. The outside source reported R1 was hallucinating, stating people were coming after them and trying to kill R1. They also reported R1 was getting up in the middle of the night and walking the halls to get away from the voices and people watching R1. R1 admitted to the outside source that they wanted to jump out of a window. The outside source admitted they did not report the concerns to the facility’s management. The outside source stated they told a caregiver and assumed it would be passed on to management. Staff interviews denied receiving knowledge from outside sources regarding R1’s paranoia or hallucinations. Interviews and records corroborated that facility staff, and physician did not document instances of suicidal ideations. The facility conducted five separate appraisals August 25, 2023, September 29, 2023, October 19, 2023, January 11, 2024, and June 9, 2024, the only change noted on the assessments was for stand by for assistance while showering, not for mental status. Further staff and outside source interviews reported R1 was thriving in the program and did not see a need to relocate R1 to the memory care unit.

The County of San Diego Death Certificate dated July 15, 2024, indicated cause of death was blunt force trauma with pelvic fractures. The manner of death could not be determined. Based on the Department’s investigation, there was insufficient evidence to deem the licensee culpable of violations of CCR Title 22. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tacy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2025

LIC809 (FAS) - (06/04)

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