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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 06/24/2021
Date Signed: 06/24/2021 03:12:18 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MIRABEL LODGEFACILITY NUMBER:
496800941
ADMINISTRATOR:SERKISSIAN, ALAIN `FACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: 32DATE:
06/24/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:50 PM
MET WITH:Josh Horn (Administrator)TIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Cuadra and Lopez arrived unannounced to the facility to conduct a case management visit to cite deficiencies discovered during a complaint investigation and met with Administrator, Josh Horn.

LPA learned through interviews on 3/22/21 with Administrator had failed to provide a resident’s records for former resident R1 who passed away on 8/1/20. Administrator stated they were unable to provide the records for R1 due to them being destroyed. Because of this Administrator was unable to provide any records or documentation for R1. During the investigation LPA reviewed records obtained from Kindred at Home (Home Health) determined that R1 had Stage III wound which is a Prohibited Condition and facility failed to notify the Department. On 3/9/20 home health documents revealed that R1 had a stage II wound which no longer was a Prohibited Condition. The Department will be scheduling a meeting to discuss areas of concerns and non-compliance for complaint # 21-AS-20201207072042.

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: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496800941
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/24/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/12/2021
Section Cited

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87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency such reports as the Department may require…(1) A written report shall be submitted to the licensing agency & person responsible for the resident within 7 days of the occurrence of any of the events…(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. This requirement has not been met as evidence by:
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Based on LPA’s records review and interviews conducted Administrator did not ensure that CCL was notified of incidents involving R1 after falls that occurred on 2019 and 2020. Home Health documents revealed that R1 had a Prohibited Condition (Stage III) wound which poses a potential health & safety risk to residents in care.
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Type B
07/12/2021
Section Cited

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Type B -87506 Resident Records (e) Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident. This requirement is not met as evidenced by

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Based on interviews and record review the licensee failed to provide resident records for R1 and stated the records had been destroyed. R1 passed away while in the facility on 8/1/20, R1 was receiving hospice services and Administrator was unable to provide care notes for R1 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: 06/24/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2021
LIC809 (FAS) - (06/04)
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