496800941-12-20-2022-21-AS-BMOS-CMJPRM-20221228103256

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800941
Report Date: 12/20/2022
Date Signed: 12/20/2022 01:22:44 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20221031104834

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:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Diandra Chadwick (Lead Staff)		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Facility does not have sufficient staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations 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.

Complaint alleges Facility does not have sufficient staff. Per Reporting Party, the facility does not have sufficient staffing to meet resident’s care needs. Based on records review, the facility is currently under a 2-year non-compliance plan starting on 7/28/2021 due to areas of concerns that included staffing issues. On 3/10/21 Licensee submitted a written policy to CCL ensuring that facility will provide staffing as follow: 4 direct care staff, 1 housekeeper, 1 kitchen for the morning shift; 5 direct care staff for the afternoon shift and 2 direct care staff for night shift.

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: 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.

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/31/2022 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20221031104834

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:	12/20/2022
		UNANNOUNCED	TIME BEGAN:	11:09 AM
MET WITH:	Diandra Chadwick (Lead Staff)		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Residents sustained unexplained bruising while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Lead Staff Diandra Chadwick.
It was alleged that residents sustained unexplained bruising while in care. Per Reporting Party, residents (R1, R2 and R3) sustained unexplained bruising on their hands while in care of night shift staff (S1, S2, S3 & S4). Based on confidential interviews conducted with facility staff, the bruising on resident’s hands became because of the two Hoyer lift machines are not working and due to short staffing, the staff have to assist residents with transfers by themselves. However, based on records review of residents, LPA obtained contradictory information due to care plans and physician report records of involved residents stated that such residents are ambulatory and do not need additional assistance for transfers. Also, facility has submitted incident reports when medical assistance had been needed for residents. Although, It is evident that R1, R2 and R3 sustained bruising, it is not known the nature of the bruising. While the evidence shows that residents has sustained unexplained bruising, it does not support the conclusion that the facility is in violation of Title 22 regulations. A finding that the complaint allegation of residents sustained unexplained bruising while in care is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221031104834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2022

NARRATIVE

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Continued from LIC9099...

During visits conducted on 12/13/22, LPA obtained staff timesheets and staff schedule for the month of November 2022 revealing that the facility is not ensuring to provide adequate staffing with a census of 31 residents in care indicates that the facility had an average of two to three caregivers on duty for residents in care during the morning, afternoon shift and one staff for night shift on the following dates: 11/4/22, 11/5/22, 11/8/22, 11/12/22, 11/18/22, 11/19/22, 12/2/22 and 12/3/22, this staff member was present to care for 31 residents. Also, based on resident’s care plans review indicates that 4 out of 31 residents required two people assist. Based on interviews conducted with Administrator, the facility had been struggling to fill in the staff schedule during the last couple weeks due to an increase of staff members calling in sick where they had been paying staff overtime and double time to ensure that there is coverage. However, they can’t bring staff on a short notice and moving forward they will be contacting staffing agencies to address this issue. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221031104834

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/20/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 01/06/2023 Section Cited CCR 87705(c)(4)	1 2 3 4 5 6 7	87705 (c) (4) Care of Persons with Dementia. There is an adequate number of direct care staff to support each resident’s physical, social, emotional, safety and health care needs as identified in his/her current appraisal. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Administrator was informed that the Department will be scheduling an informal virtual office meeting to address areas of concerns & overall compliance of the facility. Administrator agrees to submit a written plan to ensure facility is following up on residents’ needs by POC due date.
	8 9 10 11 12 13 14	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.	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: 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

LIC9099 (FAS) - (06/04)

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