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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 10/28/2024
Date Signed: 10/28/2024 06:42:35 PM

Document Has Been Signed on 10/28/2024 06:42 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 SPRINGSFACILITY NUMBER:
374603279
ADMINISTRATOR/
DIRECTOR:		TRACY KNEPPLEFACILITY TYPE:
740
ADDRESS:13075 EVENING CREEK DR STELEPHONE:
(858) 486-5020
CITY:SAN DIEGOSTATE: CAZIP CODE:
92128
CAPACITY: 184CENSUS: 155DATE:
10/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Executive Director, Tracy KneppleTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA), Natasha Persud conducted a Case Management - Incident visit. LPA met with Executive Director, Tracy Knepple and discussed the purpose of the visit.

During today's visit, LPA briefly toured the facility, requested records, and interviewed staff. The facility self reported an incident involving Resident #1 (R1). The report indicated on 10/22/24, R1 was found by an outside source on the front sidewalk near the parking lot, no injuries sustained. The facility was not aware R1 left the facility. The facility has a concierge at the front desk. However, the concierge did not notice R1 exiting the front door. R1's Physician's Report reflected R1 is not allowed to leave the facility unassisted and has a Major Neurocognitive Disorder. Per the Executive Director (ED) they were unable to redirect R1 after the incident and sent R1 out for a medical evaluation. The ED stated based on observations of R1, they believed there was a medical reason for the condition, as this was the first occurrence with R1. The ED explained R1 will be assessed upon return. In addition, ED discussed with the concierge the importance of acknowledging all people entering and exiting building at all times. The concierge was reprimanded and provided correction action.

Based on interviews, a deficiency was cited on the attached LIC 809D. 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.



SUPERVISORS NAME: Robyn Clark
LICENSING EVALUATOR NAME: Natasha Persaud
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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 10/28/2024 06:42 PM - It Cannot Be Edited


Created By: Natasha Persaud On 10/28/2024 at 02:10 PM
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: 10/28/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/25/2024
Section Cited
HSC
1569.312

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Basic services requirements. Being aware of the resident's general whereabouts, although the resident may travel independently in the community. This requirement is not met as evidenced by:
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Executive Director (ED) stated they will conduct in-service to all concierge staff regarding being aware of all individuals entering and exiting the building, especially residents that cannot leave unassisted. In addition, ED stated the concierge was give correction action.
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Based on interviews, the licensee did not ensure the safety for 1 out of 155 residents [R1] when R1 eloped from the facility without staff knowledge, which posed a potential health and safety risk to residents in care.
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ED will submit proof of training by POC due date.

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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:Robyn Clark
LICENSING EVALUATOR NAME:Natasha Persaud
LICENSING EVALUATOR SIGNATURE:
DATE: 10/28/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/28/2024


LIC809 (FAS) - (06/04)
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