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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 06/20/2022
Date Signed: 06/20/2022 10:25:09 AM


Document Has Been Signed on 06/20/2022 10:25 AM - 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MIRABEL LODGEFACILITY NUMBER:
496800941
ADMINISTRATOR:SERKISSIAN, ALAIN `FACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: 34DATE:
06/20/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:38 AM
MET WITH:Kassandra Guerrero (staff)TIME COMPLETED:
10:40 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with staff Kassandra Guerrero. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL).

On 6/15/22 LPA Cuadra received a call from staff Diandra Chadwick to report that a resident (R1) had a medical emergency and was transported to the Hospital due to issues refusing food. Per incident report, on 6/15/22 approximately at 1:00pm R1 was sent to the Hospital due to abdominal pain and low blood pressure over four weeks R1 has been refusing to eat, but was given milk shakes and offered many other options due to poor nutrition choices that had been resulting on progressively been getting weak, sleeping more. After doctor's evaluation R1 was re-admitted to receive hospice services. The facility provided R1's discharge documents dated 6/15/22 and R1 was seen for diarrhea and abdominal pain and had a diagnosis of Proctitis.

During today's visit, LPA reviewed R1's care plan including facility daily care notes were it was noted that resident have been refusing food for a while. R1's Physician's report dated 7/16/21 does not indicate that R1 was in a special diet, R1's care plan dated 12/30/21 indicates that R1 will be monitored and weight monthly for food intake and any changes will be reported to their Physician. However, the facility was unable to provide proof that R1's Physician was aware of the food refusal issues. Also, Facility did not ensure that CCL was notified about these incidents. Facility monthly weight records indicates that R1's weight had been decreasing since February 2022 from 155lbs to 134lbs as of May 2022. R1 was also receiving Home health services during 5/20/22 until 6/15/22 after R1 was admitted back to hospice services.

The facility is currently under a Non-Compliance Plan of 2 years starting on 7/28/21. The Department will be reviewing the information obtained to determine if further actions are needed. Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Civil penalties are issued today in the amount of $250 per repeated violation within 12 months.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
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 06/20/2022 10:25 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496800941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by:
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Based on LPA’s records review and interviews conducted with staff, facility did not ensure that CCL was notified of incidents involving R1 after food refusal that occurred for ovef four weeks which poses a potential health & safety risk to residents in care.
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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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2022
LIC809 (FAS) - (06/04)
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