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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 374603279
Report Date: 09/26/2024
Date Signed: 09/26/2024 04:31:35 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
05/13/2021 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20210513114116
FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: 161DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
02:11 PM
ALLEGATION(S):
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-Staff did not follow resident's care plan
-Staff did not respond to resident in a timely manner
-Licensee did not arrange appropriate medical care for resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple.

During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged staff did not follow resident's care plan. It was reported Resident #1 (R1) was receiving the highest level of care the facility offered. The level of care included two (2) persons assist but the facility was not following that. Outside sources also reported R1’s family members had to help with transfers as the facility was not providing the agreed service. R1’s Admission Agreement dated 03/03/21 confirmed the level of care being provided was Enhanced Personal Care II (EPC), which was the highest level the facility provided. The EPC II refers to all activities of daily living, to inclue two (2) persons assist. R1’s Assessment and Service Plan dated 03/03/21 reflected R1 required assistance with dressing, grooming, toileting, transfer assistance by two (2) staff members, and medication management. R1’s showers were provided by hospice. 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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
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 7
Control Number 08-AS-20210513114116
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: 09/26/2024
NARRATIVE
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Executive Director, Inan Linton stated R1 was non-weight bearing with full assistance of activities of daily living, when released from a skilled nursing facility to their facility. ED Linton also stated R1 was not a two (2) person assist but needed assistance with either a stand/sit or Hoyer lift device. However, R1’s Preplacement Appraisal dated 03/03/21, signed by ED Linton indicated R1 required assistance with transfers, bathing, dressing/grooming, moving about the facility, toileting, and medication management. The appraisal does not address two (2) persons assist. R1’s Physician’s Report dated 02/19/21 indicated R1 was bedridden and required assistance with all activities of daily living. Staff interviews revealed R1 was not two (2) persons assist. Staff stated R1 used a walker and would walk around their room and go to the bathroom on their own. Staff also stated R1 required assistance with going to the bathroom for safety reasons. According to statements made by staff, they were not following the facility’s Assessment and Service Plan dated 03/03/21, which required transfer assistance by two (2) staff members for R1.

It was also alleged staff did not respond to resident in a timely manner. Outside source interview revealed R1 had to wait over 30 minutes, and up to 45-50 minutes to get help with the bathroom. A review of R1’s Response Time document, also known as Call Button Log dated 03/04/21 thru 03/31/21 indicated multiple responses over thirty (30) minutes. On 03/05/21 response time 45 minutes 52 seconds; 03/06/21 response time was 1 hour 30 minutes; 03/08/21 response times were 42 minutes 7 seconds and another for the same date of 51 minutes 35 seconds. On 03/11/21 response times were 33 minutes 50 seconds and another for the same date of 40 minutes 8 seconds. On 03/18/21 response time was 31 minutes 55 seconds; 03/27/21 response time of 32 minutes 19 seconds; and 03/30/21 response time 59 minutes 5 seconds. Staff interviews confirmed some staff did not respond timely due to not wanting to assist residents. Resident interview confirmed late response times and having to sit in soiled diapers until the NOC shift arrived as staff came within 24 hours to check on residents during that time frame. Continued on an LIC 9099C.

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 7
Control Number 08-AS-20210513114116
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: 09/26/2024
NARRATIVE
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Lastly, it was alleged the licensee did not arrange appropriate medical care for resident. Outside source interview revealed R1 required a second Covid 19 vaccine and the facility did not arrange appropriate medical care for R1. Executive Director (ED), Inan Linton explained R1 received their first dose of the Pfizer covid-19 vaccine at the Skilled Nursing Facility (SNF) prior to admission of the facility. However, the SNF could not administer the second dose due to resident receiving a TB test, which was required to be admitted to the facility. R1 was not provided the second does at the facility’s third Covid-19 clinic on 03/06/21, due to being told that R1’s Hospice agency was administering the vaccine. However, hospice never administered the second dose, so the facility was calling around trying to find an appointment.

According to ED Linton they continued to call multiple places and found a superstation in Campo, California, which was 45 minutes away, but the only availability. The Director of Resident Care Services (DRCS) at the time signed R1 up online. During sign-up, it asked which vaccine needed, the DRCS responded, Pfizer, then the appointment was scheduled. The day of the vaccine appoint, the facility provided transportation and R1’s son accompanied them, due to R1 recovering from a fractured back. The driver called ED Linton, while at the superstation that the resident was unable to receive the vaccine as the superstation was only providing Johnson and Johnson vaccines. ED Linton started calling other locations and found one at a nearby licensed facility. The appointment was scheduled and R1’s son accompanied them. When they arrived at the licensed facility, CVS refused to administer the vaccine because they said per CDC guidelines too much time had passed. ED Linton started calling physicians and found one that came to the facility and administered the second dose of the Pfizer vaccine, to R1in their room. Based on ED Linton’s interview they did not arrange appropriate medical care for R1. The DRCS should have confirmed the vaccine being provided before the resident was transported 45 minutes away. Also, ED Linton and/or DRCS should have been aware of the CDC guidelines regarding the Covid 19 vaccination.

Based on interviews which were conducted and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be substantiated. California code of Regulations, Title 22, Division 6 & Chapter 8, are 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 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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 08-AS-20210513114116
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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
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 is not met as evidenced by:
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Executive Director stated In-Service training will be conducted with staff regarding following resident care plans.
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Based on interviews and record review, the licensee did not ensure staff were competent with following through with care plan for 1 out of 123 [R1] residents, which posed a potential health and safety risk to residents in care.
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Type B
10/17/2024
Section Cited
CCR
87464(f)(1)
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Basic Services. Basic services shall at a minimum include: Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Executive Director previously conducted In-Service training regarding Ciscor Call System Response and submitted proof of training. POC corrected.
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Based on interviews and record review, the licensee did not ensure staff respond timely to 1 out of 123 [R1] residents’ requests for assistance were over 30 minutes for staff to respond to and restore pendants, which posed 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: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 08-AS-20210513114116
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: 09/26/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/17/2024
Section Cited
CCR
87465(a)(1)
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Incidental Medical and Dental Care. The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement is not met as evidenced by:
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Executive Director stated the management team assists and arranges medical care for residents in need. There have been no issues since the former staff involved is no longer working at the facility. POC corrected.
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Based on interviews and record review, the licensee did not arrange appropriate medical care for 1 out of 123 [R1] residents. R1 was taken to multiple locations for a vaccine due to staff not confirming appropriate appointment, which posed 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: 09/26/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 7
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
05/13/2021 and conducted by Evaluator Natasha Persaud
COMPLAINT CONTROL NUMBER: 08-AS-20210513114116

FACILITY NAME:BELMONT VILLAGE SABRE SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY:184CENSUS: DATE:
09/26/2024
UNANNOUNCEDTIME BEGAN:
12:46 PM
MET WITH:Executive Director, Tracy KneppleTIME COMPLETED:
02:11 PM
ALLEGATION(S):
1
2
3
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-Licensee did not provide a safe and healthful environment for resident
-Staff did not provide food to meet the resident's needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
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10
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Licensing Program Analyst (LPA), Natasha Persaud conducted a visit to conclude the complaint investigation regarding the above-mentioned allegations. LPA met with Executive Director, Tracy Knepple.

During the investigation, records were reviewed, and interviews conducted with staff, residents, and outside sources. It was alleged the licensee did not provide a safe and healthful environment for resident. It was reported upon move into the facility Resident #1’s (R1) room was not ready. An outside source interview revealed the room was full of paint chips and plaster dust and R1 was made to wait in the hallway. In addition, R1 had a medical condition that involved trouble breathing and could not handle exposure to the room. The Executive Director, Inan Linton’s interview stated R1 came from a Skilled Nursing Facility without notice and they had to get the room ready. There were no issues, housekeeping cleaned and prepared the room within one (1) hour. 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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 08-AS-20210513114116
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: 09/26/2024
NARRATIVE
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R1 was not exposed to anything hazardous. Interviews conducted with residents expressed no issues or concerns with rooms. Staff interviews revealed many rooms were being renovated at the time. However, staff did not recall issues with R1’s room. Even though the room may have been full of paint chips and plaster dust, the facility kept R1 in the hallway, while the room was prepared. Therefore, R1 was not exposed to anything hazardous.

It was also alleged staff did not provide food to meet the resident's needs. Outside source interview revealed the food was delivered cold and late; and half the items were missing for R1. Staff interviews revealed they take the order from the resident in a computer system that is generated directly to the kitchen. Staff interviews stated there were no issues with food. Staff interviews also revealed R1 would be asleep, and the food was delivered, covered in saran wrap and placed on R1’s bedside table. Staff would then wake R1 and state the food was there and R1 would open their eyes. R1 would sleep then wake up and complain the food was cold. Further staff interview revealed R1 would order a soup, main entree, and celery/carrots. R1 would eat the soup while watching television then eat the celery/carrots, by then the main entree was cold. Staff would still offer to reheat the food. Resident interviews revealed the food was cold, never even lukewarm. Residents were able to use their microwave to reheat the food. Staff also confirmed heating resident’s food up for them if needed. During Covid 19 most facilities were having issues. Even though the food may have been served cold, the resident’s had the ability to warm their food in their microwave.

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 were deemed unsubstantiated. 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: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC9099 (FAS) - (06/04)
Page: 7 of 7