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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 12/13/2022
Date Signed: 12/20/2022 12:13:25 PM


Document Has Been Signed on 12/20/2022 12:13 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/20/2022 10:16 AM

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

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***Amended...Licensing Program Analyst (LPA) arrived unannounced to the facility and met with Lead Staff Diandra Chadwick. Licensee Alain Serkissian was not able to come to the facility but was available by phone and gave authorization to staff to sign the report. On 12/13/2022 during annual inspection at this facility, LPA issued a citation #87705 (c)(4) due to short staffing. LPA have an open investigation for complaint# 21-AS-20221031104834 alleging that facility does not have sufficient staff. LPA returned to amend annual LIC809 and LIC809D reports and will be issuing the citation under LIC9099.

Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection, Plan of Correction (POC) inspection and a case management Legal/Non-compliance inspection to this facility. During today's visit LPA met with Lead Staff, Diandra Chadwick. Administrator Alex Varshavsky arrived later. Licensee Alain Serkissian was available by phone only.


LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA/Lead staff initiated a walk-through of the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least once per day. Facility does perform daily screening of staff and residents. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and have been N95 fit tested. Facility has submitted and CCL has reviewed their Covid Mitigation Plan. Facility has more than a 30 day supply of PPE including but not limited to masks, gowns, and hand sanitizer. Facility maintains a 30 day supply of medication.

At approximate 9:20am LPA/Lead staff observed Two out of four Fire extinguishers were last serviced October 18, 2021. Smoke Detectors and Carbon Monoxide detector were operational.
At approximate 9:30am LPA/Lead staff observed one out of three water temperature reading was 109.9, 111.7 and 122.2 which is not within regulation.
Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 12/8/2022. Last disaster drill was conducted on May, 2022. Continues on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
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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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: 12/13/2022
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Continued from LIC809...

LPA/Lead Staff also observed that faucet in resident's bathroom, the dishwasher located in facility kitchen was not working and a technician was present fixing it. Also, LPA/Lead staff tested two out of two hoyer lift machine equipment that is being used to help staff with transferring residents were not working. Based on records review of residents at the facility does not have a need for Hoyer lift per their current care plans. However, residents (R1,R2, R3 & R4) requires a two person assist for transfers in their current care plans. When LPA inquired with Administrator and Licensee about it, they were not aware that those items needed to be repaired. A technical violation will be issued to address that facility is failing to provide assistance devices to help residents to meet their needs and ensure that facility maintains equipment in good repair at all times.

During today's visit LPA also followed up on POC not been cleared yet and it was due on 12/9/22. LPA previously cited facility for 87506 (c) pertaining to confidential resident records on 11/28/2022. Lead Staff showed LPA a binder named Emergency packets that includes only resident's information that could be handed to EMTS paramedics. LPA determined the new implemented system in place is appropriate and includes pertinent information. Therefore, the deficiency is cleared.

At approximate 10:30am LPA/Lead staff observed in two out of two resident's bathrooms the code alert cords are missing. LPA/Administrator discussed the requirement to have a working signal system. Per Administrator, they will follow up with company that provides services of alert system to figure out a new call system that will be able to obtain responses times.

At approximate 10:55am LPA/Lead Staff observed that the facility did not ensure that there was at least 2 day supplies of fresh fruits. Based on interviews conducted by LPA with Administrator and Licensee, there was conflicting information received about when the food delivery comes to the facility.

LPA also followed 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 self incident reports and it appears that staff had been responding timely to medical emergencies.
Continues on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
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: 12/13/2022
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Continued from LIC809C...
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/lead staff reviewed staff schedule for the month of November 2022 and facility has been assisting residents with a short staff schedule during the following time frame: 10/30/22-11/27/22; 3 staff for the morning shift instead of 4 staff, 2 to 3 staff instead of 4 staff for the afternoon shift and only 1 staff for the night shift instead of 2 staff as stated in their plan of operation. LPA reviewed staff training records and most of staff has received an average of 52 hours annual of training including care of persons with Dementia.

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/Lead staff conducted a tour through the facility and residents appeared to be safe, healthful & comfort.

CCR 87466 Observation of the Resident - Facility did not observe change of condition in resident after fall. LPA reviewed six residents (R1, R2, R3, R4, R5, R6 & R7) records and residents care plans have not been updated within the last 12 months per regulation.

CCR 87506 Resident Records - Facility wasn't able to provide CCLD with resident's care notes for review. Facility provided LPA with a new designed template to document daily resident's care notes including showering schedule, skin conditions, mental mood, out of the facility status and various notes.

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.

Facility submitted updates of the following documents: LIC 308 Designated Responsibility Administrator, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan and Liability Insurance.
Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given. The Department will be reviewing the information obtained to determine if further actions are needed.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/20/2022 12:14 PM - It Cannot Be Edited

Document is an Amendment of Original Document on 12/20/2022 10:18 AM

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: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87466
Observation of the Resident
The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interviews conducted with Administrator & Licensee, records review revealed that facility have not assessed 6 out 6 residents (R1, R2, R3, R4, R5 & R6) for a change of condition within the last 12 months per regulation which poses an immediate risk to the health and safety of the residents in care.
POC Due Date: 12/23/2022
Plan of Correction
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Administrator/Licensee agrees to submit a self-certification LIC9098 that the facility will update residents' care services plan per regulation by POC due date.
Type B
Section Cited
CCR
87705(c)(4)
87705(c)(4) Care of Persons with Dementia. Licensees who serve residents with dementia shall ensure an adequate number of direct care staff to support each resident’s needs. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs observation and record review the facility failed to ensure adequate staffing to meet residents care needs which poses a potential health and safety risk to residents in care.
POC Due Date: 12/23/2022
Plan of Correction
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***Amended...On 12/13/2022 during annual inspection at this facility, LPA issued a citation #87705 (c)(4) due to short staffing. LPA have an open investigation for complaint# 21-AS-20221031104834 alleging that facility does not have sufficient staff. LPA returned to amend annual LIC809 and LIC809D report and will be issuing the citation under LIC9099.
Administrator & Licensee agrees to submit a staffing schedule and plan to ensure staffing is adequate to meet residents needs and there is not a lack of supervision, submit staff schedule and plan to CCL 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/20/2022
LIC809 (FAS) - (06/04)
Page: 6 of 7


Document Has Been Signed on 12/13/2022 03:01 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: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
87303 Maintenance and Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on Thermometer readings, Licensee did not comply with the section cited above where 1 of 3 sinks showed a hot water temperature of 122.2F which poses an immediate risk to the health and safety of residents in care.

POC Due Date: 12/14/2022
Plan of Correction
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Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F and will submit a self-certification stating that they will follow regulation.
Type A
Section Cited
CCR
87303(i)(1)(A)(i)

87303(i)(1)(A)(i)
Facilities shall have signal systems which shall meet the following criteria:
(1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: (A) Operate from each resident's living unit.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Lead Staff observation and interviews with Licensee & Administrator. Facility did not ensure that resident's rooms had a signal system that was operational or working properly. LPA/Lead staff observed two alert cords were missing out of two locations for staff to get alerted which poses an immediate health and safety risk to residents in care.
POC Due Date: 12/14/2022
Plan of Correction
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Administrator agreed to implement a working signal system to correct the issue, facility will conduct staff training on signal system timely responses. Administrator agreed to submit a written policy in how the facility will ensure to follow the regulation 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
Page: 4 of 7


Document Has Been Signed on 12/13/2022 03:01 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: 12/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87202(a)

87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department, or district providing fire protection services, or the State Fire Marshal. This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the Administrator did not comply with the section cited above in 2 out of 4 fire extinguisher was not serviced since October 18, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 12/14/2022
Plan of Correction
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Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date
Type A
Section Cited
CCR
87555(b)(26)

87555 General Food Service Requirements (b) The following food service requirements shall apply: (26) Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA/Lead Staff’s observations and interviews with Administrator and Licensee, the facility did not ensure that there was at least a 2 day supply of perishable foods for 31 residents which poses an immediate health & safety risk for residents in care.

POC Due Date: 12/14/2022
Plan of Correction
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Administrator will submit a plan of how they will monitor food and adjust to sudden increases in the facility census. Plan for future compliance to be submitted to CCL 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: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
LIC809 (FAS) - (06/04)
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