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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 01/27/2023
Date Signed: 01/27/2023 02:22:49 PM


Document Has Been Signed on 01/27/2023 02:22 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: 31DATE:
01/27/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:29 PM
MET WITH:Diandra Chadwick (Lead Staff)TIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management inspection a regarding two incidents along with SOC341s submitted to Community Care Licensing and met with Lead Staff Diandra Chadwick.
Per incident report dated 01/17/23. On 01/13/23 while staff was passing medications overheard yelling and observed resident (R1) and resident (R2) fall to the floor holding on to a brown hat both yelling "it's mine". Staff intervene to separate both residents, assessed them for injuries. R2 did not report any pain and no injuries were observed. However, R1 complained of head and hip pain. Facility staff called 911 to transport R1 for further evaluation. During today's visit, LPA was provided a copy of hospital discharge documents dated 1/13/23 indicating that R1 was evaluated for treatment after a fall and hip pain, no new medications were prescribed and follow up was not needed. LPA conducted interviews with staff who informed LPA that they have taken the following preventive measures to avoid this type of incidents from happening again. R1 and R2 are not roommates anymore, their care plan was not been updated because according to lead staff it was an isolated incident and no further incidents have occurred between both residents. Per second incident report dated 01/19/23. On 1/17/23 lead staff received a phone call from R3's responsible party reporting that they received a call from R3 stating that R4 had swung their purse on them, striking R3's head and shoulder after having an argument. Upon receiving the call, lead staff assessed both residents for injuries, had a conversation about how they should treat each other with respect and dignity. R3 reported that their head was a bit sore and no bumps were noted by staff. After the incident, facility staff took the following preventive measures including a personal call button pendant to alert staff if there are further attempts of aggression from R4 and advised R3 that they have the right to contact the police as well if they feel threatened. R4's responsible party was also notified as well as proper agencies including CCL. R4 was relocated to a double room and a doctor's appointment was scheduled on 1/20/23 were exhibited behaviors were evaluated and a medication changes were prescribed. Per records review, On 1/25/23, R4 experienced small behaviors outbursts so the facility staff scheduled a new doctor's appointment with their primary Physician who prescribed additional medication and a follow up appointment for 2/21/23 has been scheduled. Also, R4's Psychiatrist conducted a visit on 1/26/23 to evaluate resident. The facility will update R4's care plan addressing changes. Exit interview conducted with lead staff and a copy of this report was given.
No deficiencies were cited during today's inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 01/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/27/2023
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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