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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 306003644
Report Date: 09/28/2021
Date Signed: 09/28/2021 02:55:22 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868
FACILITY NAME:MIRABEL BY THE SEA VFACILITY NUMBER:
306003644
ADMINISTRATOR:CEZAR PAGKATIPUNANFACILITY TYPE:
740
ADDRESS:249 CALLE EMPALMETELEPHONE:
(949) 498-2488
CITY:SAN CLEMENTESTATE: CAZIP CODE:
92672
CAPACITY:6CENSUS: 4DATE:
09/28/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:53 AM
MET WITH:Eloisa TolentinoTIME COMPLETED:
11:00 AM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Lyman conducted an unannounced visit for the purpose of conducting a required/ annual visit. LPA was greeted and granted entry into the facility by Caregiver Eloisa Tolentino and explained the reason for the visit. Caregiver Ricardo Bugay was present as well. Administrator Maria Velez has a current administrator certificate expiring on 12/01/2021.

At 9:15 AM, LPA toured the facility with Caregiver Tolentino. Facility has four residents in care during today's visit. LPA observed residents relaxing in the facility. All residents appeared happy and well taken care of. All resident rooms had the required elements as well as restrooms stocked with soap/ sanitizer. Two rooms are double occupancy and one is single occupancy. Facility screens all visitors to the facility and LPA observed the screening/ sanitizing station in the facility. Facility utilizes a visitor sign in sheet. Facility takes resident temperatures daily and documents. Facility has covid precaution postings as well as department postings. LPA observed the first aid kit has all required items. Facility mitigation plan has been approved. LPA observed an ample supply of emergency food and water. At 9:25 AM, LPA observed the kitchen has fruit flies flying around. As LPA went outside, LPA observed the screen door is taped and in disrepair. LPA toured the outside grounds and observed the shaded outside visitation area. Visitation area accommodations are unclean and dusty. Exit gate is unlocked and self latching. LPA observed the locked medication storage area. Facility has a plan for covid testing residents and staff as needed as well as a plan for isolation and quarantine. LPA reviewed four resident files during the visit and all files include updated emergency information. One out of four resident files do not have an updated physician report in the file. All residents and staff are vaccinated for Covid-19.

Based on the observations made during today's visit, deficiencies are being cited per Title 22 Division 6 of the California Code of Regulations. This report was discussed with the facility representative and a copy was provided as well as appeal rights.
SUPERVISOR'S NAME: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 770 THE CITY DR., SUITE 7100
ORANGE, CA 92868

FACILITY NAME: MIRABEL BY THE SEA V
FACILITY NUMBER: 306003644
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. LPA observed fruit flies in the kitchen, slider screen door is in disrepair and outside visitation area is unclean and dusty. This poses a potential health and safety risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Licensee to repair/ replace slider screen, clean outside visitation area, fumigate fruit flies and forward proof to LPA by POC due date.
Type B
Section Cited
CCR
87705(c)(5)
Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in one out of four resident files. Resident 1 has a physician report dated 08/01/2019 with a diagnosis of Dementia. This poses a potential health and safety risk to persons in care.
POC Due Date: 10/12/2021
Plan of Correction
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Licensee to obtain an updated physician report for Resident 1 and forward proof to LPA by POC due date.
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: Alisa OrtizTELEPHONE: (714) 703-2855
LICENSING EVALUATOR NAME: Kimberly LymanTELEPHONE: (714) 795-1497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2021
LIC809 (FAS) - (06/04)
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