496800941-10-5-2022-21-AS-MCUA-CJWN5X-20221005101015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 10/05/2022
Date Signed: 10/05/2022 10:10:21 AM

Document Has Been Signed on 10/05/2022 10:10 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 LODGE		FACILITY NUMBER:	496800941
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 31	DATE:	10/05/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Alex Varshavsky (Administrator)		TIME COMPLETED:	10:24 AM

NARRATIVE
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	Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and met with Administrator Alex Varshavsky. LPA was following up on items that were concerning and ensure compliance with Non-Compliance Conference dated 7/28/21: CCR 87465(g) - Incidental Medical and Dental Care - Facility failed to seek timely medical attention. LPA reviewed one self incident report about hospitalization that occurred on 10/2/22 and 10/4/22 for two residents (R1 & R2). However, CCL has not received incident reports yet. Although, the incidents are within 7 days as indicated per regulation. HSC 1569.269 (a)(5) Enumerated Rights - Facility did not ensure that resident was accorded safe, healthful and comfortable accommodations which resulted in resident’s death as a result of a serious fall at the facility. LPA/Administrator observed residents who appeared to be safe, healthful and comfort. CCR 87211 Reporting Requirements - Facility did not ensure that CCL was notified about incidents after falls occurred on 2019 and 2020 including resident with Prohibited Condition (Stage III) wound. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations. CCR 87705 (c)(4) Facility didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Administrator reviewed staff schedule for the month of September 2022 and facility appears to have sufficient staff for each shift to help with resident's needs. LPA reviewed staff training records and most of staff (S1, S2, S3, S4, S5 & S6) has received an average of 56 to 71 hours annual of training including care of persons with Dementia. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

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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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
	VISIT DATE: 10/05/2022

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Continued from LIC809...

CCR 87466 Observation of the Resident - Facility did not observe change of condition in resident after fall. LPA reviewed six residents (R3, R4, R5, R6 and R7) records and residents have been assessed for change of condition within the last 12 months per regulation.

CCR 87506 Resident Records - Facility provided LPA with resident's care notes for review. Facility provided a notebook with supplemental resident's care notes to document daily resident's care notes including showering schedule, skin conditions, mental mood, out of the facility status and various notes. LPA/Administrator observed daily care notes document for each resident.

No deficiencies cited during today's inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2022

LIC809 (FAS) - (06/04)

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