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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 08/24/2021
Date Signed: 08/25/2021 09:25:30 AM

Document Has Been Signed on 08/25/2021 09:25 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:INAN LINTONFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 184CENSUS: 129DATE:
08/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:31 PM
MET WITH:Executive Director, Inan LintonTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA identified herself and discussed the purpose of the visit with Executive Director, Inan Linton.

During today’s visit, LPA briefly toured the facility. The reason for the visit is to issue deficiencies that were identified during a complaint investigation. Investigation revealed Resident #1 (R1) sustained five (5) pressure injuries resulting in hospitalization due to neglect by facility staff. R1 was being treated for the pressure injuries at the facility by Home Health (HH) and a Mobile Wound Care (MWC) service. R1 received wound care services from 07/02/20 through 07/13/20. On 07/04/20, Home Health documented the five (5) pressure injuries and diagnosed them as: two (2) pressure injuries on the lower right leg were Unstageable, due to being covered 100% in black eschar; one (1) pressure injury on the bilateral buttock was a Stage I; one (1) pressure injury on the right earlobe was a Stage II; and one (1) pressure injury on the left lower lateral leg was Unstageable, due to being covered 100% in black eschar. The Mayo Clinic defines pressure injuries can be classified into four (4) stages of increasing depth and severity, known as Stages one (1) thru four (4). However, they also have additional stages that exist known as unstageable injuries. Unstageable injuries are described as covered by dead tissue or eschar that obscures the ulcer base.

During services being provided, the facility did not obtain a plan of care from the Home Health Agency to provide the supporting care and supervision needed to meet the needs of R1. Thus, some R1’s pressure injuries continued to progress to, “unstageable”. Facility staff interviews revealed they requested the plan of care multiple times but did not receive it and did not continue to follow up. A pressure injury that progresses beyond a stage 2, is deemed a prohibited health condition and the license is required to submit a written exception request if he/she believes that the intent of the law can be met through alternative means. The facility did not request an exception for R1’s prohibited health condition per Title 22 Regulations. Continued on LIC 809C.
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2021
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
CCLD Regional Office, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108
FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279
VISIT DATE: 08/24/2021
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Lastly, R1’s primary care physician sent a physician’s order via fax to the facility on 06/23/20 indicating to keep R1’s legs propped up on a pillow when in wheelchair to off-load pressure on legs. Staff interviews revealed R1’s legs were not being off-loaded as prescribed on 06/23/20. Title 22 Regulations require staff to be competent to provide the services necessary to meet resident’s needs. However, staff did not follow physician’s orders, obtain a plan of care or request a prohibited health condition exception.

Based on interviews and record review the licensee was found in violation and therefore per California code of Regulations, Title 22, Division 6 & Chapter 8 the licensee is being cited on the attached LIC 809D. An exit interview was conducted, and a copy of this report and Licensee Rights (LIC 9058 01/16) were provided to Executive Director via electronic mail. An electronic mail read receipt was requested to be provided upon receipt of the documents. [See LIC 811 Confidential Names List to identify Resident #1].
SUPERVISORS NAME: John Rante
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE:

DATE: 08/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/24/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 08/25/2021 09:25 AM - It Cannot Be Edited


Created By: Natasha Persaud On 08/24/2021 at 11:52 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited
CCR
87609(b)(2)

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Allowable Health Conditions and the Use of Home Health Agencies. Incidental medical care may be provided...through a licensed home health agency...the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs...receiving home health care.
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Executive Director (ED) agreed to have staff in charge of obtaining required documentation to include care plans attend training provided by an outside vendor. ED will schedule the training and provide proof of scheduled training by POC due date. In addition, ED will provide proof of training within 2 weeks.

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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not provide the supporting care and supervision needed to meet the needs of 1 [R1] out of 129 residents, receiving home health care. This posed an immediate health risk to residents in care.
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Type A
08/25/2021
Section Cited
CCR87411(a)

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Personnel Requirements – General. 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 was not met as evidenced by:
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Executive Director (ED) agreed to have staff trained on complying with physician orders by an outside vendor. ED will schedule the training and provide proof of scheduled training by POC due date. In addition, ED will provide proof of training within 2 weeks.

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Based on interviews and record review, the licensee did not ensure physician’s orders were followed for 1 [R1] out 129 residents, which caused R1’s pressure injuries to progress. This posed an immediate health 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:John Rante
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 08/25/2021 09:25 AM - It Cannot Be Edited


Created By: Natasha Persaud On 08/24/2021 at 11:58 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 7575 METROPOLITAN DR. #109
SAN DIEGO, CA 92108

FACILITY NAME: BELMONT VILLAGE SABRE SPRINGS
FACILITY NUMBER: 374603279

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/31/2021
Section Cited
CCR
87616(a)

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Exceptions for Health Conditions. As specified in Section 87209, Program Flexibility, the licensee may submit a written exception request if he/she agrees that the resident has a prohibited and/or restrictive health condition but believes that the intent of the law can be met through alternative means.
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Executive Director (ED) agreed to have staff trained by an outside vendor on recognizing prohibited health conditions. ED will schedule the training and provide proof of scheduled training by POC due date. In addition, ED will provide proof of training within 2 weeks.
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This requirement was not met as evidenced by: Based on interviews and record review, the licensee did not request an exception for a prohibited health condition regarding unstageable pressure injuries for 1 [R1] out of 129
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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:John Rante
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2021


LIC809 (FAS) - (06/04)
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