374603279-3-28-2025-08-AS-NPED-DF7U4F-20250328151505

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 03/28/2025
Date Signed: 03/28/2025 03:15:16 PM

Document Has Been Signed on 03/28/2025 03:15 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	TOTAL ENROLLED CHILDREN: 0	CENSUS:	DATE:	03/28/2025
TYPE OF VISIT:	Case Management - Deficiencies	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:23 PM
MET WITH:	Memory Program Coordinator, Aiyana Martinez		TIME VISIT/ INSPECTION COMPLETED:	02:00 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 an unannounced Case Management visit to conclude an incident investigation. LPA met with Memory Program Coordinator, Aiyana Martinez. On September 24, 2024, the Department received an Unusual Incident Report from the facility regarding an incident involving Resident #1 (R1). According to the facility's report, R1 sustained a fall on September 21, 2024, and a facility nurse assessed R1 and observed grimacing and a lack of movement on the left side of their body. The nurse recommended an evaluation by emergency services; however, both R1 and their responsible party declined and R1 was not treated by medical professionals. As a result, the Department opened an investigation into the delayed medical care of R1. A review of R1’s Physician’s Report, dated July 31, 2024, indicated a diagnosis of Major Neurocognitive Disorder (MND) and stated that R1 required assistance with bathing. The report also noted that while R1 could communicate their needs, they experienced a loss of intellectual function, including difficulty making decisions. A review of R1’s Assessment/Service Plan, dated September 3, 2024, indicated that R1 required assistance with bathing, dressing, grooming, and escort assistance while walking to meals and facility-planned activities. A review of R1’s facility records reflected that R1 had a fall on July 28, 2024, and complained of wrist pain. R1 was taken to the hospital by their responsible party and was advised to return for a cast once the swelling subsided. Further record review indicated that R1 fell again on July 29, 2024. Facility staff called 9-1-1, and R1 was transported to the hospital, where they were diagnosed with a hematoma on the back of their head. Additionally, on July 31, 2024, R1 self-reported increased pain in their left arm, prompting facility staff to call 9-1-1 for transport to the hospital for further evaluation. Continued on an LIC 809C.

Robyn Clark	TELEPHONE: (619) 767-2312
Natasha Persaud	TELEPHONE: (619) 301-3594
	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 03/28/2025

NARRATIVE

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Facility records also reflected additional falls involving R1 on the following dates: August 2, 2024, when R1 complained of left arm pain but was only monitored; August 24, 2024, with no reported pain; and September 11, 2024, when R1 sustained a small cut on their forehead. Paramedics responded and provided care for the injury.

On September 21, 2024, R1’s responsible party was assisting R1 with a shower in their room. When the responsible party heard a knock at the door and stepped away to answer it, R1 fell in the shower, landing on their left side. The person at the door was a caregiver who immediately responded to assist R1 and called the on-duty facility nurse. The nurse conducted a head-to-toe assessment and noted no visible injuries. R1 was able to move all extremities; however, they grimaced when reaching for the shower bar with their left hand. The nurse recommended that R1 be transported to the hospital for evaluation, but both R1 and their responsible party declined. The responsible party indicated they would take R1 to the hospital if their pain persisted. The facility placed R1 on “alert charting” to monitor them more frequently for pain or changes in condition.

On September 26, 2024, the on-duty nurse became concerned when R1 did not want to get out of bed for breakfast or lunch. The nurse called R1’s responsible party to express concerns, stating they believed R1 might be experiencing pain from the fall on September 21, 2024, or possibly had a urinary tract infection. The nurse recommended R1 be transported to the hospital by ambulance, but R1’s responsible party stated they would take R1 themselves. They drove R1 to an urgent care, where R1 was diagnosed with non-operable rib fractures on the left side. As a result, R1’s responsible party transported R1 to the hospital for further care.

The Executive Director (ED) stated in an interview that R1 had experienced an increase in unwitnessed falls in their room since August 2024, which they attributed to R1’s cognitive decline. The ED also stated that after each fall, R1 was assessed by a facility nurse, and on some occasions, the nurse recommended that R1 be transported to the hospital for evaluation. When 9-1-1 was called, R1’s responsible party would often arrive before the paramedics and sign an Against Medical Advice (AMA) refusal, declining hospital transport for R1.

The Director of Resident Care Services (DRCS) confirmed in an interview that there were instances when the facility nurse recommended that R1 be sent to the hospital for evaluation, but R1’s responsible party refused medical care. Continued on an LIC 809C.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

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: 03/28/2025

NARRATIVE

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The DRCS also stated that on September 21, 2024, after R1’s fall, the on-duty LVN assessed R1 and found no visible injuries. However, R1 complained of pain when stretching out their arm and experienced pain in their side and lower back. Despite the facility nurse’s recommendation for hospital transport, R1’s responsible party declined medical services. The DRCS further indicated that on September 26, 2024, the nurse became concerned when R1 refused to get out of bed for breakfast or lunch. The facility nurse contacted R1’s responsible party to express concerns that R1 may have been experiencing pain from the September 21, 2024.

In an interview, R1’s responsible party confirmed that on September 21, 2024, R1 expressed having pain in their hip and lower back but noted that this had been an ongoing issue. The responsible party admitted they were unsure whether they made the right decision by not taking R1 to the hospital after the fall. They also acknowledged that there had been instances when facility staff suggested R1 be transported to the hospital, but they were unwilling to do so every time R1 fell if there were no visible injuries or complaints of pain.

A review of hospital records dated September 27, 2025, revealed that upon arrival, R1 was diagnosed with acute fractures in ribs 8–11 on the left side and subacute fractures on the right side.

Based on a review of the evidence, the licensee did not immediately telephone 9-1-1 for R1, who had fallen, was expressing pain, and could not get out of bed due to experiencing extreme physical pain, solely because R1’s responsible party verbally refused medical care. While residents have the right to refuse medical care, the licensee remains responsible for ensuring that appropriate medical care is arranged. In this case, R1 would have had the right to refuse care against medical advice (AMA) in the presence of emergency medical technicians (EMTs) and/or emergency room medical professionals.

Based on the Department’s investigation, the licensee was found in violation. A citation under California Code of Regulations, Title 22, Division 6, Chapter 8, is issued on the attached LIC 809-D. The licensee was informed that a civil penalty might be assessed based on Health and Safety Code 1569.49(f).

An exit interview was then conducted with Memory Program Coordinator, Aiyana Martinez. The report was reviewed, and a plan of correction was jointly developed. At the conclusion of the visit, Memory Program Coordinator, Aiyana Martinez was provided with copies of the report, LIC 811 – Confidential Names List identifying Resident #1, and LIC 9058 – Licensee/Appeal Rights. The signature below confirms receipt of these documents.

SUPERVISOR'S NAME: Robyn Clark	TELEPHONE: (619) 767-2312
LICENSING EVALUATOR NAME: Natasha Persaud	TELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/28/2025 03:15 PM - 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
SAN DIEGO RO, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS	FACILITY NUMBER: 374603279
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/29/2025 Section Cited CCR 87465(g)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health...except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).	1 2 3 4 5 6 7	Memory Program Coordinator, Aiyana Martinez contacted the Executive Director via telephone and agreed to have staff trained on calling 911 for timely medical care. Proof of scheduled training by POC due date and submit proof of training within 2 weeks.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: Based on interviews and records review the licensee did not call 9-1-1 on September 21, 2024, and/or on September 26, 2024, for 1 [R1] out of 158 residents, which posed an immediate health and safety to residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Robyn Clark	TELEPHONE: (619) 767-2312
Natasha Persaud	TELEPHONE: (619) 301-3594
	DATE: 03/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2025

LIC809 (FAS) - (06/04)

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