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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 374603279
Report Date: 06/23/2022
Date Signed: 06/24/2022 01:14:31 PM


Document Has Been Signed on 06/24/2022 01:14 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
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: 153DATE:
06/23/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Director of Resident Care Services, Jacqueline ToupinTIME COMPLETED:
02:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management visit. LPA met with Director of Resident Care Services, Jacqueline Toupin and we discussed the purpose of the visit.

On 05/06/2021, the Department substantiated a complaint alleging neglect/lack of supervision of Resident #1 (R1). A citation under Title 22 Regulations 87465(g) was issued. On today’s date, the Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.

An exit interview was conducted and a copy of this report, LIC 421IM – Civil Penalty Assessment Form, and Licensee Rights (LIC 9058 01/16) were provided to Director of Resident Care Services, Jacqueline Toupin whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1].

SUPERVISOR'S NAME: Lizzette TellezTELEPHONE: (619) 767-2351
LICENSING EVALUATOR NAME: Natasha PersaudTELEPHONE: (619) 301-3594
LICENSING EVALUATOR SIGNATURE:
DATE: 06/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
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 06/24/2022 02:36 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 06/24/2022 02:19 PM

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/23/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/23/2022
Section Cited

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Civil penalties; regulations setting forth appeal procedures for deficiencies. The department shall assess an immediate civil penalty of five hundred dollars ($500) per violation and one hundred dollars ($100) for each day the violation continues after citation for...the department determines resulted in the injury or illness of a resident.
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This requirement is not met as evidenced by: Based on interviews and review of record, the licensee did not contact 911 or obtain emergency medical services for (R1) 1 out of 121 residents, when R1 developed a Stage II pressure injury that progressed to unstageable. This posed an immediate health and safety risk to R1.
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The Department is issuing a $500.00 civil penalty under HSC 1569.49(c)(1), for a violation that the Department determined resulted in an injury of R1.

This is an amended version of the original report created on 06/23/22

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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: 06/23/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/23/2022
LIC809 (FAS) - (06/04)
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