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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:52:49 PM


Document Has Been Signed on 03/13/2023 03:52 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: 29DATE:
03/13/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:06 PM
MET WITH:Alex Varshavsky (Administrator)TIME COMPLETED:
04:07 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance and change of ownership inspection to this facility and met with current 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 incident report logs received 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/Lead Staff 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/Lead staff reviewed staff schedule for the month of February 2023 and facility has 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 to help with resident's needs. LPA reviewed staff training records and most of staff (S1, S2, S3, S4 & S5) has received an average of 56 hours annual of training including care of persons with Dementia.

Continues on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: 03/13/2023
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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 (R1, R2, R3, R4 and R5) 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/Lead staff observed daily care notes document for each resident.

LPA/Lead staff initiated a tour of the facility at 1:15 pm and made the following observations: The facility was clean and well organized. Smoke; Carbon Monoxide, all current. First aid kit fully stocked. Resident bedrooms and bath appropriately furnished and clean.

At approximate 1:30pm LPA/Lead staff observed exits for room# 2 was blocked and unable to open for exit. Room#4 exit was obstructed with a burgundy sofa. Room# 6 a small fridge was observed blocking the exit. Lead staff removed furniture and objects that were blocking the exit immediately. **Immediate Civil Penalty assessed in the amount of $500.

At approximate 1:45pm LPA/Lead staff observed all resident's rooms auditory alarm system were not operational or working properly. **Immediate Civil Penalty assessed in the amount of $250 for repeated violation.

LPA will submit copy of the facility report to the Centralized Application Unit and inform of citations, exits obstructed and auditory alarms not functioning properly. LPA to conduct subsequent pre-licensing inspection after POC's are cleared.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Appeal rights given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/13/2023 03:52 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: 03/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/14/2023
Section Cited

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87203-All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic.

This requirement was not met as evidenced by:
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Licensee to ensure walkways and exits are unobstructed. Licensee to review fire code regulations and submit self-certification that items blocking exits have been removed. Administrator shall provide proof of staff training on fire code regulations by April 9, 2023.
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Based on LPAs observation & interview with lead staff, the facility did not ensure to be in compliance by blocking exit door in the resident's room (#2, 4 & 6) leading to the exit ramp to the backyard which poses an immediate health and safety risk to residents in care.
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 **Immediate Civil Penalty assessed in the amount of $500.
Type A
03/14/2023
Section Cited

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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.

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Administrator agreed to implement a working signal system to correct the issue, facility will install auditory alarms in resident's rooms. Administrator agreed to submit a written policy in how the facility will ensure to follow the regulation by POC due date.
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Based on LPA/Lead Staff observation and interviews with Administrator. Facility did not ensure that resident's rooms had a signal system that was operational or working properly. LPA/Lead staff observed all resident's rooms auditory alarms were not working properly which poses an immediate health and safety risk to residents in care.
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 **Immediate Civil Penalty assessed in the amount of $250 for repeated violation.
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: 03/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3