Belmont Village Sabre Springs.

Licensing Program Analyst (LPA) Nacole Patterson conducted an unannounced Case Management Visit.  LPA was greeted by and met with Executive Director Tracy Knepple, to discuss the purpose of the visit. Today's visit is in response to the self report regarding an emergency water shut off on 02/12/2026 due to a pipe leak. The investigation showed that the Maintenance Director observed a small pipe leak in the Memory Care building and initiated emergency maintenance the same day with a facility contractor. The memory care unit was informed that the hot water would be turned off from 7:00pm to 10:00pm and preparations were made not to shower residents during that time due to having cold water only. During the repairs the contractor observed an additional issue, resulting in a larger portion of hot water needing to be turned off suddenly. Due to the unexpected problem, it was not possible for the facility to provide timely notice to residents without significant consequences to the facility plant and increased resident safety risk. No residents were harmed during the incident. LPA conducted a wellness check at the facility; no health or safety issues were identified. No deficiencies were cited or observed on this date. The investigation showed that the facility responded to an emergent situation and took immediate measures to prevent risk to residents. An exit interview was conducted with Tracy Knepple, Executive Director, who was provided with a copy of this report and Appeal Rights (LIC9056 03/22).  Their signature confirms receipt of these documents.

(Continued on LIC9099 p.2) Staff were also spot-trained on a random basis regarding fire emergencies and what to do. Staff provided information regarding the process during emergency procedures, which was consistent with facility records and procedures regarding emergencies. Resident 1 (R1) was interviewed during an unannounced facility visit. R1 stated that their main concern was what felt like a delay in communication regarding the "all clear", after staff confirmed the incident to be a false alarm. R1 acknowledged that during the time of the incident, staff were assisting all residents in the community, including residents with higher care needs. R1 informed they appreciated their feedback to the facility being taken seriously, and R1 has been involved in updating the resident-facing communication regarding what to do in emergencies. Records review revealed consistent emergency training conducted by staff annually and monthly, which corroborated staff statements. R1's pendant log showed that R1 received assistance from staff 22 minutes and 30 seconds after pushing their pendant, which was during the false alarm. During an unannounced facility visit LPA directly observed the location where the fire alarm was pulled, the alarm stations, fire extinguishers, and fire alarms throughout the building. The observations made by LPA were consistent with staff interviews, resident interview, and records reviewed. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violation occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tracy Knepple, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

An Office Meeting was conducted to review the Stipulation and Waiver and Order adopted on September 18, 2025. Those present for the Department of Social Services (Department) were: Jerry Romero, Regional Manager Sabel Martinez, Licensing Program Manager Present for Belmont Village Sabre Springs were: Douglas Armstong, Senior Vice President of Regulatory Affairs Tracy Knepple, Executive Director Regional Manager reviewed and discussed the agreed upon and Adopted Decision and Order dated September 18, 2025. Douglas Armstrong and Tracy Knepple understands the following is required for compliance with the Order. An exit interview was conducted with Douglas Armstrong and Tracy Knepple to whom copies of this report and Licensee Rights were provided. A new license will be issued with the probationary status indicated. A signature from Tracy Knepple on this form acknowledges receipt of the report and rights.

(Continued from LIC9099 p.1) Resident interviews did not corroborate the allegation. Residents stated that staff treated them well and expressed no concerns. R1 was interviewed during the facility visit and stated that staff treated them well. R1 did not express concerns about staff treating them disrespectfully; R1 stated they were happy with the care they received and stated they would change nothing about the care provided at the facility. Outside source interviews did not corroborate the allegation. An outside advocacy agency familiar with the facility stated that they had no concerns regarding residents' being treated with dignity by staff. R1's Responsible Party informed that staff treated R1 very well and stated they had no concerns regarding staff treatment toward R1. No records were found to give evidence to this allegation. Staff records were absent of write-ups regarding staff treating a resident without respect. Care notes for R1 were absent of any situations regarding lack of respect/dignity by staff. LPAs directly observed resident care during the facility visit. LPAs observed staff assisting residents with programmed activities, in groups, and activities of daily living (ADLs). These observations include times when staff were unaware of the LPAs' presence. LPAs did not observe any staff member engage with a resident in a disrespectful way. Regarding the allegation, "Staff left medication(s) in resident's room", it was alleged that unsecured medication was left in Resident 2 (R2)'s room. Staff interviews did not corroborate the allegation, as staff denied seeing any unsecured medications in a resident room who was unable to administer their own medications. Resident interviews did not corroborate this allegation. Five (5) residents were interviewed regarding medications, 3 of whom informed they administered their own medications. One resident only received pro re nata (PRN) "as-needed" pain medications and informed that there were no issues. R2 refused interview, however, LPAs briefly observed R2's room and noted that no loose medications were observed in the room. Two outside sources familiar with the facility were interviewed regarding medication administration. The outside sources did not express concerns about medication administration and had not been made aware of any medication issues. (Continued on LIC9099 p.3) 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 26 27 28 29 30 31 32 (Continued from LIC9099 p.2) No records were found to give evidence to this allegation. Staff records were absent of write-ups regarding medications being left in a resident's room. R2's assessments revealed that R2 did not administer their own medications. Care notes for R2 during the timeframe of complaint were absent of any incidents where medications were found in R2's room. Notations existed in R2's Care Notes regarding missed medications, however those situations were due to R2's refusals of the medication pass. Regarding the allegation, "Resident left facility unassisted", it was alleged that Resident 3 (R3) left the facility without required staff supervision. Staff involved in the incident informed that R3 possibly experienced an episode of delusion during the incident due to observing paranoid behaviors outside of R1's baseline. Staff interviews additionally revealed that R1 was able to leave the facility unassisted, however, due to staff's concerns regarding R1's mental state, staff accompanied R1 as they left the facility, and additional staff responded to their location as well as R3's responsible party and paramedics. R3 was unable to be interviewed due to being out of the facility during the facility visit. An outside advocacy agency familiar with the facility did not have concerns about residents leaving unassisted and had not been made aware of any situations where a resident left the facility without required supervision. This outside source also did not have concerns about general resident supervision at the facility. Review of facility records revealed that the incident was reported as required. R3's Physician's Report did not indicate that R3 was unable to leave the facility unassisted. The incident report details were consistent with staff interviews that R3 was accompanied by staff when they left the facility. Facility records additionally revealed that R3 was not noted to require wearing a Wander Guard. R3's charting notes were consistent with staff statements regarding R3's episode of delusion, wanting to leave the facility, and staff accompanying them outside. R3's Charting Notes also showed that R3 was assisted in the community by staff. Based on interviews, direct LPA observations and records review, a preponderance of evidence does not exist to prove that the alleged violations occurred, therefore the allegations are UNSUBSTANTIATED. An exit interview was conducted with Executive Director Tracy Knepple, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Licensing Program Analysts (LPAs) Nacole Patterson and Jose De La Cruz conducted an unannounced Required Annual Inspection. The facility file was reviewed prior to the visit. LPAs were welcomed by and discussed the purpose of the visit to Executive Director (ED) Tracy Knepple. The facility's license shows a maximum capacity of 184 non-ambulatory residents, ages 60 and above, it is approved for 32 bedridden and 23 in hospice waiver. Facility is equipped with delayed egress and secured perimeter. During today’s inspection there were 149 residents in care. LPAs and ED toured the interior and exterior of the facility and inspected each room. The facility was clean, sanitary, and in good repair. Pathways were free of obstruction and slip hazards. Client bedrooms contained the required furnishings. Doors, windows, screens, toilets, and showers were in working order. Extra linens and hygiene supplies were present, as well as Personal Protective Equipment. The facility had sufficient space and equipment to facilitate dining, laundry, visitation, meetings, and client activities. The facility contained at least 2 days of perishable food, and at least 7 days non-perishable food, all safely stored. Cooking, dining equipment, and utensils were present. No toxic chemicals or poisons were accessible to clients. Medications were labeled, as required, and stored in locked areas. The facility has a pool that was locked and inaccessible to residents. Per ED, no firearms or ammunition are kept at the facility. Carbon monoxide detectors, emergency lighting, and facility telephone were all in working order. Fire extinguishers were serviced within the last 12 months. First aid kits were complete and readily accessible. Required licensing postings were observed in visible areas of the facility. LPAs interviewed staff and clients, and reviewed facility records. The files reviewed by LPAs contained required documents. Confidential records were stored in locked areas. No deficiencies were cited during the inspection. An exit interview was conducted with ED to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided.

Regarding the allegation, neglect resulting in resident sustaining pressure injuries, it was reported that Resident (R1) sustained pressure injuries as a result of the facilities’ neglect. A records review revealed a doctor’s note dated 5/22/2023 stating that R1 had stage 2 pressure injuries, and it was ordered that R1 was to receive wound care twice a week and be repositioned every two hours. Records review showed that hospice nurses visited R1 and provided wound care. Interview with outside source (OS1) revealed that R1 was provided wound care by hospice nurse and was repositioned by private caregiver. Interviews with facility staff revealed that staff reposition residents who are at risk of pressure injuries every two hours and reported no concerns for resident neglect. Regarding the allegation, neglect resulting in resident sustaining an infection in mouth, it was reported that R2 sustained a rash in the mouth due to facility neglect. Records review revealed that R2 was prescribed medication Nystatin to treat infection in mouth and was seen by a Home Health agency. Records review show that there was a delay in getting the signed doctor’s order for the Nystatin due to the doctor’s office not sending over the order. Records review showed the facility advocating for the resident by calling the doctor’s office and requesting to follow up on doctor’s order. Interviews with facility staff revealed that staff had no concern for facility neglecting residents and reported that all residents are cared for. Interviews with residents revealed no concerns. Interview with outside source (OS2) revealed that staff reported the infection in R2’s mouth immediately and medical attention was sought out. Regarding the allegation, staff did not seek medical attention in a timely manner, it was reported that residents have made complaints such as being in pain and staff do nothing. Interviews with facility staff revealed no concern for residents not receiving timely medical attention. Interviews with residents revealed no concern for delay in seeking medical attention. Interview with outside source (OS2) revealed no concern for residents not receiving timely medical attention. Regarding the allegation, residents are not treated with dignity, it was reported that residents are not allowed to go outside. LPA conducted a walk through of facility and observed several doors that lead to outside area to be unlocked and accessible to residents. Interviews with staff revealed that residents are allowed to go outside, and facility has ample outside area for residents to utilize. Interviews with residents revealed that there is an outside area for residents to go to that is always available. Interview with outside source (OS1) revealed that facility has an outside area, and residents are able to go to outside area. Continued on an LIC 9099C. 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 26 27 28 29 30 31 32 Regarding the allegation, facility does not provide activities to residents in care, it was reported that residents are not provided any activities. LPA observations revealed that an activities calendar is posted in multiple areas of the facility, including elevators, entrance of memory care and hallways. LPA observed morning exercise activity being conducted in memory care unit. Interviews with residents revealed that there are activities every day. Interviews with facility staff revealed that activities are offered daily and are changed every month. Regarding the allegation, facility has rodents, it was reported that rodents have been found in the kitchen. LPA toured facility kitchen and did not observe any rodents or any indication that facility has rodents. Interviews with facility staff revealed no concern for rodents at the facility. Interviews with residents revealed no concern for rodents. Regarding the allegation, facility is in disrepair, it was reported that the facility ceiling is leaky and moldy, there is owl feces leaking through the walls of the Casa Blanca Room, and resident 3 (R3)’s wall paint is chipping and in disrepair. LPA did not observe any leaky or molding areas in facility ceiling. LPA observed Casa Blanca Room (on bottom floor in memory care) and did not observe any owl feces leaking through walls. LPA observed R3’s room and observed wall paint to be intact and not chipping or peeling. LPA did not observe any concern for the building and grounds while conducting a walk through. Interviews with facility staff revealed no concerns for facility being in disrepair. Interviews with residents revealed no concern for building and grounds or cleanliness of facility. Interview with outside sources (OS1 & OS2) both revealed no concerns for building and grounds. Based upon the foregoing, the above listed allegations are unsubstantiated. This finding means that the preponderance of the evidence standard has not been met, and the allegations are not valid. No deficiencies were cited today. 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 via email. [See LIC 811 Confidential Names List to identify Resident #1 and #2]

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director (ED), Tracy Knepple and discussed the purpose of the visit. The facility self reported an incident regarding Resident #1 (R1). On 03/23/25, R1 had an unwitnessed fall, injuring their r ight hip and middle finger. ED explained R1 was independent and managed their own medication. Approximately nine (9) months ago, R1 was no longer independent and required assistance with activities of daily living, but could transfer independently and used a walker for long distances. The facility acted appropriately with medical care and contacted 911. R1 was transported to the hospital and diagnosed with a hip fracture. R1's responsible party decided against surgery for the hip fracture. R1 returned to the facility and was already receiving hospice services for comfort care. ED stated the care plan was updated to follow physician orders. ED also stated they continued to monitor for change of condition in partnership with hospice. Per the ED, R1 qualified for hospice services based on a medical condition, unrelated to the fracture. On 03/28/25, R1 passed away at the facility with their family by their side. 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.

Licensing Program Analyst (LPA), Juliana Barfield arrived on April 8, 2025 for an unannounced inspection to follow up on an incident investigation reported by the facility. LPA met with Tracy Knepple. On March 28, 2025, the Department concluded an incident investigation regarding a self-reported incident involving delayed medical care to resident (R1). The licensee was cited for California Code of Regulations (CCR) § 87465(g) Incidental Medical and Dental Care. At the time of the case management visit on March 28, 2025, the licensee was informed that a civil penalty might be assessed based on Health and Safety Code § 1569.49(f). The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation.” This is evidenced by 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. Today, April 8, 2025 the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes a serious bodily injury to R1 in the amount of $10,000.00. Exit interview conducted. A copy of the report issued. Appeal rights provided to Tracy Knepple and signature on this report acknowledges receipt of the appeal rights, found on page two of LIC 421D.

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. 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 26 27 28 29 30 31 32 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. 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 26 27 28 29 30 31 32 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.

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management – Other visit. LPA met with Executive Director, Tacy Knepple and discussed the purpose of the visit. The facility self reported an incident regarding Resident #1 (R1). On July 7, 2024, R1 was witnessed falling from the third floor balcony of the facility. The facility contacted 911 immediately after discovering R1. R1 was transported to hospital for further medical evaluation. On July 12, 2024, the resident passed away at the hospital. During the investigation, the facility was toured, records reviewed, and interviews conducted with staff, residents, and outside sources. R1’s Preplacement Appraisal dated July 24, 2023, indicated R1 had a Major Neurocognitive Disorder, was very impulsive, and lacked awareness of objects/obstacles close by. The appraisal did not reflect suicidal ideations. R1’s Physician Report dated October 19, 2023, indicated R1 was ambulatory, confused, depressed, unable to communicate needs, and required assistance with bathing, dressing/grooming, and toileting. R1 resided in the Assisted Living (AL) portion of the facility. The facility documented the Major Neurocognitive Disorder and determined R1 was safe and did not require their secured memory care unit. Based on the facility’s assessments, R1 did not have exit seeking behaviors. In addition, R1’s family member’s interview revealed they did not want R1 in the secured memory care unit, as R1 was doing well and progressing with the program. R1 was part of a program called Circle of Friends at the facility. The program was designed as a bridge from AL to memory care. Residents have the ability to attend the program and live in AL, while attending activities to assist with continued independence. Once the resident is no longer able to attend the program due to increased confusion/memory loss or exit seeking behavior, they may transition into the memory care unit. Circle of Friends is located on the third floor of the building, with balcony access. Staff interviews confirmed they were not aware of any suicidal ideations. A review of resident records did not reflect any suicidal ideations but indicated depression. Continued on an LIC 809C. 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 26 27 28 29 30 31 32 R1 was receiving medical treatment and medication for the depression. Outside source interview revealed R1’s family member was aware R1 was having difficulty. The outside source reported R1 was hallucinating, stating people were coming after them and trying to kill R1. They also reported R1 was getting up in the middle of the night and walking the halls to get away from the voices and people watching R1. R1 admitted to the outside source that they wanted to jump out of a window. The outside source admitted they did not report the concerns to the facility’s management. The outside source stated they told a caregiver and assumed it would be passed on to management. Staff interviews denied receiving knowledge from outside sources regarding R1’s paranoia or hallucinations. Interviews and records corroborated that facility staff, and physician did not document instances of suicidal ideations. The facility conducted five separate appraisals August 25, 2023, September 29, 2023, October 19, 2023, January 11, 2024, and June 9, 2024, the only change noted on the assessments was for stand by for assistance while showering, not for mental status. Further staff and outside source interviews reported R1 was thriving in the program and did not see a need to relocate R1 to the memory care unit. The County of San Diego Death Certificate dated July 15, 2024, indicated cause of death was blunt force trauma with pelvic fractures. The manner of death could not be determined. Based on the Department’s investigation, there was insufficient evidence to deem the licensee culpable of violations of CCR Title 22. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Executive Director, Tacy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1]

LPA reviewed video footage for 11/04/24, there were no female residents leaving or entering the building from 4:45am to 6:45am. Both exits that are not secured were reviewed and determined there was no resident elopement. LPA also reviewed the sign in and out log, which did not include any female residents, for the date and time in question leaving or entering the facility. During the course of the investigation interviews were conducted. Investigation revealed inconsistent statements and information obtained did not present a preponderance of evidence to support or corroborate the allegation. The allegation was 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.

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.

Licensing Program Analyst (LPA), Natasha Persud conducted a Case Management - Incident visit to check on the health and safety of residents in care. LPA met with Executive Director, Tracy Knepple. During today's visit, LPA briefly toured the facility, collected records, observed resident's in care and spoke with staff concerning the health and safety of residents. LPA did not observe any immediate health and/or safety violations and after speaking with residents did not receive any complaints about their health. 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.

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management -Other visit. LPA met with Executive Director, Tracy Knepple. On 08/01/24, the facility applied for a secured perimeter. There was a delay with the Fire Department granting an incorrect reason instead of secured perimeter. On 09/13/24, the Fire Department revised the fire clearance and approved the facility for secured perimeter. LPA toured the facility's perimeter and observed it was locked and secured. No deficiencies were observed during today's visit. 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.

There are no concerns for bacteria or food poisoning. Resident interviews confirmed they have not gotten ill from the facility food. The Executive Director also confirmed eating the facility’s food on a regular basis and never gotten ill. It was also alleged the facility is not clean and in good repair. An outside source reported that on 8/19/2024 they were informed that the kitchen was very dirty, and several kitchen equipment items were broken. The outside source confirmed they did not observe the kitchen. The Chef Manager’s interview revealed there was a Low Boy fridge out of service. The didn't use the Low Boy and it was thrown out and a new one was delivered within 2 weeks. The Chef Manager also stated the staff clean the kitchen daily, wiping down, sweeping, mopping, and sanitizing. LPA observed the kitchen on 08/28/24, all equipment was in good repair and working order, and the kitchen was clean. Residents were not interviewed because they do not enter the kitchen. The Executive Director (ED) stated if equipment is broken it’s immediately repaired or replaced. The ED confirmed the Low Boy fridge was broken and a new one was ordered and delivered on 07/31/24, which was prior to the reported date of incident. 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.

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management visit - Other. LPA met with Executive Director, Tracy Knepple. Today, LPA was at the facility for an investigation. During the resident interviewing process. LPA observed Resident #1 (R1) sitting in the common area near their apartment. LPA approached R1 and they stated they were not feeling well and had Covid-19. R1 also had their apartment door open, allowing exposure. The facility did not follow their infection control guidelines by ensuring the resident was isolated. The Executive Director was made aware of R1 sitting in the common area. The ED requested R1 to return to their apartment and explained keeping other residents safe. The ED also stated she will have staff conduct rounds to ensure Covid-19 positive residents are isolated per infection control guidelines. A deficiency was issued and 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.

Licensing Program Analyst (LPA) Carmen Lopez conducted an unannounced Collateral visit for an investigation unrelated to this facility. LPA identified herself and was granted entry by Diane Forsythe, concierge. LPA met with Tracy Knepple, Executive Director, and discussed the purpose of the visit. During today’s visit, LPA requested and obtained records (see LIC811 Confidential Names list). There were no deficiencies observed or cited during today’s visit. An exit interview was conducted with Tracy Knepple, Executive Director, to whom a copy of this report, LIC811, and the Licensee/Appeal Rights (LIC9058 03/22) were provided at the conclusion of the visit. The signature below confirms the receipt of these documents.

ED stated Belmont’s corporate staff and a dietician designed the menu to ensure all options are low carbohydrates, excluding the beverages and desserts. The ED explained the admission agreement outlines the diets offered at the facility, prior to the resident and/or responsible party signing. The Director Resident Care Services (DRCS) indicated all menu options have moderate carbohydrate amounts and is proportioned appropriately. R1 requires carbohydrates and the order does not state no carbohydrates. DRCS confirmed the menu is tailored to accommodate a low carbohydrate diet for all residents. DRCS explained the facility does not offer a diabetic diet. Therefore, a resident would have to relocate to an appropriate facility that accommodates a diabetic diet. Outside source interviews revealed R1 was being served waffles with syrup, hamburgers, and baked potatoes. Outside source interviews also revealed R1 sits at the dining table and eats multiple sugar packets. The outside source would like the sugar packets removed from the table. However, that would be a violation of residents’ personal rights. DRCS confirmed the high sugar content items on the menu would be the beverages and desserts. The staff will offer sugar free options for beverages and desserts. However, they cannot force the resident to choose sugar free options, especially since the facility does not offer a diabetic diet. The Chef Manager’s interview revealed the menu offered to residents consists of no added salt and low carbohydrates. The Chef Manager also confirmed the portions are not the portion sizes served at a restaurant. The facility serves potatoes that are small, approximately 3oz; the waffles are mini size and only two (2) are served; and the burger is approximately 2-2.5 oz. Therefore, the resident can select any of the items due to the low carbohydrate content and portion size. Chef Manager also stated the server is aware of any special/modified diets and they will offer the resident sugar free syrup, other sugar free options, and will also try to persuade the resident to make good choices. However, the resident has personal rights and is allowed to choose any items. If the staff notice a resident isn’t making wise choices, such as ordering double portions then it’s reported to the nurse for follow up with the resident’s physician. There have been no issues with R1, they select their own meals and eat in the dining room. Facility’s correspondence dated 06/17/24 indicated R1’s responsible party wanted the facility to stop serving breads, pasta, cookies, potatoes, sugar packets, sugary drinks/desserts. However, R1 requires carbohydrates per the physician’s order. Also, R1 has the cognitive ability to make their own food choices. The facility is offering a low carbohydrate diet and R1 has the right to make their own choices. 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 allegation. The allegation was 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.

Licensing Program Analyst (LPA) Natasha Persaud conducted an unannounced Case Management - Incident visit. LPA met with with Executive Director, Tracy Knepple. Today, the facility was briefly toured, records requested and interviews conducted with staff and resident. The facility self reported an incident regarding Resident #1 (R1). On 07/12/24, R1 was witnessed falling from the third floor balcony of the facility. The facility acted appropriately and contacted 911, R1 was transported to hospital for further medical evaluation. R1 passed away at the hospital the same day. No deficiencies were issued today. 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. [See LIC 811 Confidential Names List to identify Resident #1].

Staff also reported they can return the food items and request better quality. Executive Director’s interview revealed they recently had to hire a new cook due to unforeseen circumstances. However, ED has not heard of food complaints and believes the cook is doing a good job. It was also alleged the licensee did not ensure resident records are current. Title 22 Regulations require residents with a diagnosis of a Major Neurocognitive Disorder have an annual medical assessment. A review of records indicated Resident #1 (R1) and Resident #2 (R2) both have a Major Neurocognitive Disorder did not have current medical assessments. R1’s Physician’s Report was dated 08/18/22 and R2’s Physician’s Report was dated 07/12/21. The Physician’s Reports were collected on 02/09/24. 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 Director of Resident Care Service, Keisha Bean whose signature below confirms receipt of these rights. 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 26 27 28 29 30 31 32 Outside sources reported staff were using thickener powder for R2’s water due to R2 repeatedly requesting water. Staff interviews revealed R2 tends to repeatedly ask for water due to their medical condition. Further staff interviews confirmed R2 was provided water when requested but also monitor R2’s water consumption for safety. Staff also stated a prescription was needed for thickener power, which R2 does not have. Staff denied using thickener powder. On 02/09/24, LPA observed R2 repeatedly requesting water and receiving it. R2’s interview confirmed they are being provided water upon request. It was reported R3 was being kept from going to their room. Staff interviews stated residents are encouraged to participate in activities and they prefer residents in the common areas. However, residents can go to their room any time. All residents are provided with a key to their room. The resident rooms lock automatically to prevent wandering residents. The residents have a Major Neurocognitive Disorder and are assisted to their rooms by staff or can independently go to their room. R3’s interview confirmed they are not being kept from going to their room. On 02/09/24, LPA observed R3 requesting to go to their room and staff assisted. It was also reported R4 was being denied bathroom use. Staff interviews revealed R4 has a medical condition that makes R4 believe they have to frequently use the bathroom. Staff interviews also revealed the facility was working with R4’s family regarding the urgency to use the bathroom. On 02/09/24, LPA observed R4 request an escort to use the bathroom. Staff assisted R4 to their bedroom to use the bathroom. Once R4 was done and returned to the common area, they immediately asked to use the bathroom and commented they never used the bathroom. R4’s interview confirmed they can use the bathroom whenever they like. It was also alleged staff did not treat residents with dignity. It was reported R1 was called an inappropriate word by staff and told hurtful things about R1’s family members. Also, R3 will repeatedly ask the same question due to their Major Neurocognitive Disorder and told by staff that their parents were dead, each time R3 asks for them. Resident interviews revealed denial of being called inappropriate words or being told anything negative about their families. Staff interviews confirmed they are not using inappropriate words or negative comments towards residents. It was also alleged staff did not allow residents to use their own personal possessions. It was reported Resident #5 (R5) was denied the use of their eyeglasses. Continued on an LIC 9099C 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 26 27 28 29 30 31 32 Staff interviews revealed R5 has many pairs of eyeglasses and will set them down in different places due to their forgetfulness. Therefore, the family bought R5 multiple pairs. The eyeglasses are not prescribed by a physician, but store-bought reading glasses. On 02/09/24, LPA observed R5 was wearing a pair of glasses and had a pair hanging from the middle of their sweater. R5’s interview revealed they always have access to their eyeglasses. It was also reported Resident #6 (R6) was being denied access to their hearing aids. Staff reported R6’s hearing aids are kept at the desk of the Director of Memory Care for safety and charging. Staff’s interview confirmed they are aware of the process for R6’s hearing aids. Outside source interviews confirmed staff charge R6’s hearing aids then bring them for R6 daily. Outside sources also stated there were times the hearing aids were not charged. However, R6 was never denied the use of them. On 02/09/24, LPA observed R6 was wearing charged hearing aids. It was also alleged staff did not meet residents’ hygiene needs by not showering and changing residents’ clothing for days. Staff interviews revealed residents are showered according to their shower schedule and clothing is changed daily. Outside source interviews revealed R5 has worn the same clothing for two to three days consecutively. Staff interviews stated R5 has trouble seeing and will usually spill food on their clothing. However, R5’s clothing is changed daily. Additional outside sources revealed R6 was observed in the same clothing for three days consecutively. However, it was a one-time occurrence. On 02/09/24, LPA observed R5 had food spilled on their clothing, staff confirmed R5 just had lunch. LPA also observed R6, who was clean and dressed well. LPA has observed R6 on multiple occasions while visiting the facility and R6 was kept clean. Residents are being showered accordingly and clothing changed daily. Resident interviews confirmed they are being showered and clothing changed daily. 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 are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 03/22) were provided to Director of Resident Care, Keisha Bean whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Residents 1-6]

LPA Licensing Program Analyst (LPA) Tiffany Holmes conducted an unannounced Case Management – Incident visit. LPA was welcomed by, identified herself to, and discussed the purpose of the visit with Director of Resident Care Keisha Bean. Today's visit was in response to an LIC 624 Incident Report, which licensee self submitted to the CCLD San Diego Regional Office (received on 06/17/2024). According to the LIC 624: during the morning of 06/11/2024, Resident 1 (R1) exited the facility and walked along the street out front of the facility. R1 was picked up by the facility driver and was returned safely to the community. R1 was assessed by staff with no injuries noted and also met with staff to discuss their reason for leaving. After speaking with the resident, R1 expressed an understanding of not leaving the facility unassisted again and that if they want to leave they will seek assistance. During today’s visit, LPA performed a brief facility tour and collected copies of and reviewed pertinent records. LPA also interviewed relevant staff. According to their latest LIC 602 Physician’s Report (dated 01/29/2024), R1 was diagnosed with Mild Cognitive Impairment (MCI) and required staff assistance with taking their prescribed medications and it is documented that the resident is not able to leave the facility unassisted. An exit interview was conducted with Bean, to whom a copy of this report, and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.

Licensing Program Manager (LPM) Simon Jacob arrived on June 7, 2024 for an unannounced case management visit to follow up on a substantiated complaint investigation. LPM Simon Jacob met with Director of Resident Care Services, Keisha Bean , and reviewed the report. On May 6, 2021, the Department concluded a complaint investigation which alleged that a resident sustained multiple pressure injuries resulting in hospitalization due to staff neglect . The allegation was substantiated, and the licensee was cited under California Code of Regulations § 87465(g) – Incidental Medical and Dental Care, which states in part, “ 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...” On August 24, 2021, the licensee was also cited, on case management, three violations as a result of the complaint. The first deficiency was cited under California Code of Regulations, Title 22 § 87609(b)(2), Allowable Health Conditions and the Use of Home Health Agencies, which states in part, “Incidental medical care may be provided to residents through a licensed home health agency provided the following conditions are met: The licensee provides the supporting care and supervision needed to meet the needs of the resident receiving home health care.” The second deficiency was cited under California Code of Regulations, Title 22 § 87411(a) Personnel Requirements – General, which states in part, “Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.” The third deficiency was cited under California Code of Regulations, Title 22 § 87616(a), Exceptions for Health Conditions, which states in part, “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.” At the time of the complaint visit on June 23, 2022, an immediate civil penalty of $500 was assessed and the licensee was informed that an additional civil penalty might be assessed based on Health and Safety Code § 1569.49. 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 26 27 28 29 30 31 32 The Department has concluded an analysis and has determined that a civil penalty is warranted for serious bodily injury. The Welfare and Institutions Code Section § 15610.67 defines serious bodily injury as "an injury involving extreme physical pain, substantial risk of death, or protracted loss or impairment of a function of a bodily member, organ, or of mental faculty, or requiring medical intervention, including but not limited to, hospitalization, surgery, or physical rehabilitation . This is evidenced by the licensee’s failure to contact 9-1-1 or obtain emergency medical services when they observed an imminent threat to the health of the resident, failure to obtain a written plan of care from the home health agency and mobile wound care provider for the new and ongoing pressure injuries, failure to conduct a reappraisal, failure to train and supervise facility staff responsible for providing supporting care and supervision, and for failure to ensure staff followed physician’s orders which contributed to the development of the pressure injuries and infection that emitted foul odors and required medical intervention, including hospitalization and maggot debridement therapy. Today , June 7, 2024 , the Department will be issuing a civil penalty per Health and Safety Code § 1569.49 for a violation that the Department constitutes as serious bodily injuries in the amount of $10,000. However, since an immediate civil penalty of $500 was previously assessed on June 23, 2022, the amount of the civil penalty issued today will be $9,500. A copy of the LIC 421D was given to Director of Resident Care Services, Keisha Bean and originals were signed. An exit interview was conducted, a copy of the report was issued, and Appeal Rights were provided. Director of Resident Care Services, Keisha Bean's signature on this report acknowledges receipt of the Appeal Rights, found on page two of LIC 421 D.

Licensing Program Analyst (LPA), Natasha Persaud conducted an unannounced Plan of Correction visit. LPA met with Executive Director, Tracy Knepple and discussed the purpose of the visit. On 02/22/24, the facility was issued a deficiency for the facility being disrepair, regarding an air conditioning unit having a leak. The Executive Director had the air conditioning unit replaced. Today, LPA observed the air conditioning unit has been replaced and the deficiency has been corrected. No deficiencies were observed. 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.

Licensing Program Analyst (LPA), Natasha Persaud conducted a Case Management - Incident visit. LPA met with Executive Director, Tracy Knepple. The facility self reported an incident that occurred on 12/01/23 involving Resident #1 (R1). The report stated R1 was observed with injuries and R1 was unable to explain what happened. R1 was transported to the hospital for evaluation and returned the same day back to the facility with no new orders Today, LPA reviewed records and interviewed staff and R1. There were no indications of a violation. No deficiencies were observed today. 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.

On both occasions, staff were present with R1 and had line of sight supervision. As staff were following R1, they stayed on the phone with the manager in charge providing details and location. Staff interviews confirmed R1 was safe with staff and did not sustain any injuries. Staff also confirmed they never lost sight of supervision with R1. Evidence obtained revealed there was no lack of supervision, as staff were present with R1 the entire time R1 was out of the facility and in the community. It was also alleged staff did not treat R1 with dignity. Outside source interviews revealed staff were rude to R1 by telling R1 to get back in their room and close the door. Staff interviews revealed R1 had family visiting frequently with small dogs that were not leashed. Therefore, staff asked R1 to go back into their room and close the door. Staff explained being worried about the other resident’s safety because the residents could trip on the small dogs or their leashes, plus some feared dogs. Resident interviews confirmed they were treated with dignity by staff. It was also alleged staff can’t communicate with residents due to a language barrier. Outside sources reported some staff do not speak English. Staff interviews revealed there were no language barriers, as all staff spoke English. The Human Resources Generalist explained speaking English is a requirement for the job. Therefore, all staff speak English. Additional outside source interviews confirmed there was no language barriers with staff and have been able to discuss resident care needs. Resident interviews confirmed they understand staff and there were no language barriers. It was also alleged staff mismanaged residents’ medication. Outside sources reported Resident #2 (R2) shared the same first name as R1 and R2 was given R1’s medications. Outside source interviews revealed staff were asked to review medications with outside source. During the review, the staff member accidentally pulled the medication for R2 and showed them to the outside source. The medication was not dispensed, only reviewed. The outside source confirmed no medications were dispensed or administered to either resident, as it was just a review. Staff also confirmed there were no medication errors involving either resident with the shared first name. Continued on an LIC 9099C. 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 26 27 28 29 30 31 32 Lastly, it was alleged staff did not meet resident’s medical needs. It was reported there was an order on file to check R1’s blood sugar levels and ensure R1 used their CPAP machine at night. However, the orders were not being followed. A review of R1’s Medication Administrator Record indicated R1 was receiving blood sugar checks as prescribed. The facility did not have an order on file for a CPAP machine for R1. Some staff interviews revealed not being aware of the CPAP machine and unable to assist with CPAP machine as they were not trained. Other staff observed the CPAP machine in R1’s room but never noted it in use or an order on file. Further staff interviews revealed there was a discussion with R1’s family that an order would be needed but they never brought the machine or order. R1’s records did not indicate the need or use for a CPAP machine. 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 are deemed unsubstantiated. An exit interview was conducted and a copy of this report along with Licensee Rights (LIC 9058 01/16) were provided to Executive Director, Tracy Knepple whose signature below confirms receipt of these rights. [See LIC 811 Confidential Names List to identify Resident #1 and Resident #2]

Licensing Program Analyst (LPA) Dang Nguyen conducted an unannounced Case Management - Health Checks visit. LPA was welcomed by, identified himself to, and discussed the purpose of the visit with Executive Director Tracy Knepple. During today's visit, LPA briefly toured the facility, performed a health and safety welfare check on residents in care, and spoke with staff. No deficiencies were observed or cited on this date. An exit interview was conducted with Knepple, to whom a copy of this report and the Licensee/Appeal Rights (LIC9058 03/22) were provided during the visit.