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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 11/28/2022
Date Signed: 11/28/2022 12:03:13 PM


Document Has Been Signed on 11/28/2022 12:03 PM - 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:VARSHAVSKY, ALEXANDERFACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: 30DATE:
11/28/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Diandra Chadwick (Lead Staff) TIME COMPLETED:
12:18 PM
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Licensing Program Analyst (LPA) Cuadra arrived at this facility unannounced to conduct a case management visit in regards to a couple self-incident report along with death report submitted to CCL on 10/29/2022 and met with lead staff, Diandra Chadwick. Administrator Alex Varshavsky was not able to come to the facility but was available by phone and gave authorization to staff to sign the report.

On 10/29/22 LPA received a self-incident report along with death certificate for resident (R1). Per incident report, on 10/28/22 R1 was having dinner when suddenly slumped to one side of the chair in the dining room and face began to drop to the right side. Staff (S1) was assisting other residents in the dining room when noticed and started to assess R1 to check if resident was responding and reached out to another staff (S2) to call 911. Upon paramedics arrived, they transported R1 to Kaiser for further evaluation. S1 notified lead staff and lead staff notified R1's responsible party. R1 was treated for massive brain bleed. Per death report dated 11/3/22, R1 passed away on 10/30/22 while in the hospital due to brain bleed.

During today's visit, LPA attempted to review R1's records including LIC602 Physician's report and care plan. However, LPA was informed that S2 gave the entire binder to paramedics and now is missing. LPA discussed with Administrator that resident's records shall be kept confidential. LPA obtained R1's death certificate issued on 11/4/22 that indicates large left intraparenchymal hemorrage, etiology unknown as the immediate cause of death with hypertension as contributing condition to the cause of death. Based on interviews conducted with facility staff, R1 did not fall from the chair because S1 noticed when resident's face started to drop.

Another incident report was received on 10/29/22 notifying CCL about resident (R2). Per incident report, on 10/22/22 R2 was complaining of pain in their left hand. Lead staff (S3) assessed R2's hand and noticed that their ring finger was deformed, causing a lot of pain and unable to move the finger.
Continues on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
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: 11/28/2022
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Continued from LIC809...

S3 inquired with R2 if they had a fall and R2 replied yes, but I got up. Then S3 contacted 911 to transport R2 to the emergency room for further evaluation and notified R2's responsible party. R2 was treated for dislocated finger and returned to the facility using a brace for the finger for 10 days. R2 had injured the same finger the prior week and ER nurse reported that the ligament and tendons were very fragile and that the left ring finger joint could easily slip out again.

During today's visit, LPA reviewed resident's records including R2's Physician report dated 7/21/22 that indicates that R2 has a primary diagnosis of dementia and Parkinson, care plan dated 10/26/20 indicates that R2 is not at fall risk. However, R2 needs an updated assessment annually that has not been performed since 10/26/20. R2's discharge documents dated 10/22/22 revealed finger injury due to a witnessed fall and resident was seen on 10/2/22 for the same problem as stated in the incident report received at CCL on 10/2/22 and 10/22/22.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/28/2022 12:03 PM - 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: 11/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/09/2022
Section Cited

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87506 Resident Records (c) All information and records obtained from or regarding residents shall be confidential. This requirement has not been met as evidence by:
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Based on interviews the facility staff failed to provide resident records for R1 and stated the records were handed to EMTS paramedics and now they are missing which poses a potential health and 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: 11/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2022
LIC809 (FAS) - (06/04)
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