496800941-10-20-2020-21-AS-BMOS-BUSRYC-20201027132606

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800941
Report Date: 10/20/2020
Date Signed: 10/20/2020 02:26:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2020 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20200622090554

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496800941
ADMINISTRATOR:	SERKISSIAN, ALAIN `		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 29	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Josh Horn (Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff assisting with the administration of medication have no traning to pass out medications.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra contacted Josh Horn Administrator, on October 20, 2020 by telephone for the purpose of delivering findings on complaint # 21-AS-20200622090554. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

It was alleged that “staff assisting with the administration of medication have no training to pass out medications”. Based on a review of 10 staff training records as of June 23, 2020. 2 out 10 staff (S1 and S2) who assist in the administration of medications do not have the required training within the last 12 months. LPA conducted interviews and was informed by Administrator that S3 pass out medications to residents and doesn’t have required training. Administrator informed LPA that staff helps passing out medications during emergencies only. Administrator provided staffing schedules for the month of June 2020 and it was revealed that S3 passed out medications to residents on June 9, 2020.

Continues on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200622090554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496800941
	VISIT DATE: 10/20/2020

NARRATIVE

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Continued from LIC9099...

On 9/8/20 LPA conducted interviews with 5 out of 10 staff (S1, S3, S4, S5 and S6) and obtained conflicting information regarding the last time they received medication training versus proof of training records submitted to CCL. However, staff informed LPA that after all they went thru and given the circumstances, they probably don’t have an accurate date of their last training received.

Based on records review and interviews conducted with staff, the preponderance of evidence standard has been met, therefore the above allegation of staff assisting with the administration of medication have no training to pass out medications is found to be SUBSTANTIATED. Health and Safety Code is being cited on the attached LIC 9099D. Appeal Rights Given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/22/2020 and conducted by Evaluator Marisol Cuadra

COMPLAINT CONTROL NUMBER: 21-AS-20200622090554

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496800941
ADMINISTRATOR:	SERKISSIAN, ALAIN `		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS:	DATE:	10/20/2020
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Josh Horn (Administrator)		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Staff did not give medication as prescribed by physician.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra contacted Josh Horn Administrator, on October 20,2020 by telephone for the purpose of delivering findings on complaint # 21-AS-20200622090554. Due to COVID – 19 precautions a facility visit is not able to be conducted at this time.

During the investigation LPA reviewed records and conducted interviews with staff and various parties. It was alleged that staff was not providing medication to hospice residents (R1 and R2) as prescribed by physician. Based on records review of R1’s doctor order dated 3/9/20, R1 was referred to hospice (Continuum). LPA obtained R1’s needs and services plan dated 3/12/20, Hospice Plan of Care dated 3/10/20 and conducted interviews with R1’s hospice nurse who clarified that they were not responsible to pass medications to residents. Regarding R1, nurse informed LPA that there was nothing noticed about medication. LPA learned that medication was modified a few months ago due R1’s change of condition. However, it was revealed that at one point it seems like R1 was too sleepy and medication dosage was modified by doctor; but it did not appear that R1 was not given their medicine as they were supposed to.
Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200622090554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496800941
	VISIT DATE: 10/20/2020

NARRATIVE

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Continued from LIC9099A...

LPA conducted interviews with 5 out of 10 staff (S1, S3, S4, S5 and S6) who assist in the administration of medications and it was learned that R1 was all over the place, very anxious which was addressed on their plan of care, R1 started to slow down after doctor changed their medication due to change of condition. Regarding R2, LPA reviewed records and learned that R2 moved into the facility on 6/19/20 at 12:30pm and passed away the same day 6/19/20 at 11:03pm. Administrator informed LPA about a discussion with responsible party to have R2 initiate hospice which was confirmed with interviews conducted with S5 who revealed that R2 was observed upon admission very sleepy and notified Administrator and responsible party. S5 started the process of coordinating the transfer of medication orders to their pharmacy when R2 passed away the same day of their admission.

LPA conducted interviews with 5 out of 10 staff (S1, S3, S4, S5 and S6) who assist in the administration of medications and learned that the protocol is that administrator or shift leaders will pre-pour within 24 hours medications for am and pm, they will put it on trays that are kept locked in the office with resident’s names on it which staff will take and provide medication to resident one by one, they wait to make sure resident takes their medication as prescribed and they will documented into the MARS. LPA obtained death certificate of R1 and R2 for review which indicates cause of death not related to allegation.

A finding that the complaint allegations that staff did not give medication as prescribed by physician is unsubstantiated meaning that although the allegation may have happened there is not a preponderance of evidence to prove that the allegations occurred.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20200622090554

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496800941
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2020

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/03/2020 Section Cited HSC 1569.69(b)	1 2 3 4 5 6 7	HSC1569.69 (b) Each employee who received training ... required & continues to assist with the self-administration of medicines, shall also complete 8 hrs of in-service training on medication-related issues in each succeeding 12-month period. This requirement was not met based on evidence by:	1 2 3 4 5 6 7	Administrator to have S1 and S2 staff complete the annual required medication training and submit proof of training to CCL by POC due date of 11/3/2020.
	8 9 10 11 12 13 14	Based on record review & interview with administrator, facility failed to ensure that S1 and S2 had the required number of ongoing medication training hours per regulation which poses a potential safety risk.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2020

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2020

LIC9099 (FAS) - (06/04)

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