496800941-6-24-2021-21-AS-BMOS-C4HTH3-20210701144404

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800941
Report Date: 06/24/2021
Date Signed: 06/24/2021 03:10:50 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/03/2021 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20210303091703

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496800941
ADMINISTRATOR:	SERKISSIAN, ALAIN `		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 32	DATE:	06/24/2021
		UNANNOUNCED	TIME BEGAN:	02:34 PM
MET WITH:	Josh Horn (Administrator)		TIME COMPLETED:	03:25 PM

ALLEGATION(S):

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-Staff neglect resulting in resident developing pressure injuries while in care.
-Staff did not safeguard resident’s personal belongings.
-Resident's hygiene needs were not being met.
-Resident developed a bacterial infection while in care.
-Resident's medication is missing.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cuadra and Lopez arrived unannounced to the facility met with Administrator, Josh Horn to deliver findings regarding the complaint allegations above.
Complaint alleged that staff neglect resulted in resident, R1 developing pressure injuries while in care. Per reporting party, staff put the protective booty on the wrong foot and a picture of R1’s foot dated 2/2/2020 was provided to CCL. Based on confidential interviews conducted on April 29, 2021 and May 25, 2021, LPA was not able to prove or disprove that staff neglected on placing boot in the wrong foot. Reporting party provided picture of R1’s wound dated 12/29/19. LPA obtained records for R1 dated December 23, 2019 from Healdsburg District Hospital where R1 was receiving wound care from their Physician. Also, LPA obtained and reviewed 778 pages provided from Kindred at Home (Home Health) dated from November 23, 2019 until July 2020. Home health was conducting visits two to three times per week in average to provide wound care to R1’s left foot; while R1 was provided wound care from home health, documentation show that R1 experienced pressure wound that their body was unable to heal and general decline in health that resulted in R1 was admitted to receive hospice care on July 30, 2020. Care notes of home health nurses who helped provide wound care for R1 did not observe evidence of neglect from care staff and indicated that the responsible party was informed of R1’s status. Continues on LIC9099C…

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20210303091703

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/24/2021

NARRATIVE

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Continued from LIC9099…

Based on records review provided from Heartland Hospice dated from July 29, 2020 until August 1, 2020 no signs of abuse or neglect from care staff was observed. Based on records review of R1’s service notes dated December 13, 2019 from Kindred at Home indicated that R1 had a history of falls with an injury in the past year. Also, per service notes dated December 31, 2019 R1 had an un-witnessed fall. On June 12, 2020 R1 had another un-witnessed fall with a scrap on forehead, responsible party was notified. However, LPA reviewed incident report logs for this facility, and it was determined that incident reports were not submitted to CCL. Administrator could not provide proof that incidents were reported to CCL. LPA will address reporting requirements on a case management inspection. A finding that the complaint allegations “Staff neglect resulting in resident developing pressure injuries 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.

Regarding allegation of resident developed a bacterial infection while in care. Reporting Party further reported that the resident also developed more pressure injuries but was not sure where the pressure injuries were located. Based on records review of home health care notes dated June 2, 2020 some redness without any sign of infection, no open sores or broken skin was observed on R1’s coccyx. On July 30, 2020 Heartland Hospice records indicated that R1 was admitted to hospice services with a diagnosis of MRSA (of the heel). However, R1 was receiving care from home health and no signs of actual or potential abuse or neglect from staff was observed. A finding that the complaint allegations “Resident developed a bacterial infection 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.

Regarding allegation of Staff did not safeguard resident’s personal belongings. Reporting party alleges that resident’s (R1) ring was stolen and when they insisted the staff returned a ring, but it wasn’t the same ring. Reporting party provided pictures of the ring dated February 20, 2020 located on R1’s finger; Also, reporting party provided a picture dated October 20, 2020 of a different ring that it was given to them. LPA reviewed records of LIC621 form which is used by facility to document resident’s personal property and valuables upon resident’s admission. LIC621 form indicated that only 1 item was documented and described as Audio Aid VA dated November 15, 2017, the form was signed between Administrator and responsible party. Interviews conducted with staff indicated that R1’s personal belongings were collected by responsible party after R1 passed away. Based on records review and interviews conducted with staff and responsible party, LPA was unable to either prove or disprove the above allegations. A finding that the complaint allegations “Staff did not safeguard resident’s personal belongings ” 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.

Continues on LIC9099C...

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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 21-AS-20210303091703

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
	VISIT DATE: 06/24/2021

NARRATIVE

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Continued from LIC9099C…

Regarding allegation of Resident's hygiene needs were not being met. It was alleged that R1’s fingernails were not being cut, their teeth not being brushed, R1 was not being shaved. Also, staff were placing three diapers on R1 so that they did not have to change them, and they had seen R1’s clothes soaked in urine. Reporting party provided different pictures where it was observed a picture dated February 20, 2020 showing R1’s right thumb with a yellow nail that appears to have fungus in the edge of the nail. R1 was observed with facial hair on their chin, this picture was dated January 6, 2019. LPA was provided with other pictures dated September 30, 2018, July 21, 2019 and October 2019 where R1 was observed well groomed and cleaned. On April 29, 2021 LPA made observations and conducted confidential interviews with staff and residents in care which were observed clean and well groomed. Facility provided documentation of needs and services plan annual evaluation dated and signed on January 30, 2020 by responsible party and Administrator which indicated that facility will provide full assistance with bathing, hygiene/oral care and incontinence care. LPA learned through interviews on April 29, 2021 with Administrator had failed to provide R1’s records 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, issue will be addressed in a case management. Based on records review of records provided from different agencies who provided wound care to R1 including Home Health, Hospital Records and Hospice services there was no evidence that R1’s hygiene needs were not being met. A finding that the complaint allegations “Resident's hygiene needs were not being met” 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.

Regarding allegation of Resident's medication is missing. Reporting Party reported that the R1 was receiving medication (Gabapentin) and it was causing R1 to sleep all day and medication was missing. Based on records review R1 was prescribed with Gabapentin 100mg (2 tabs PO QAM and 4 tabs PO QHS) since November 17, 2017. On February 10, 2020 the dosage was increased to Gabapentin 300mg (1 capsule at bedtime for agitation and sleep). Based on facility records provided of Centrally Stored Medication and Destruction log all doses of medications were listed on the facility medication records to have been dispensed as ordered by the resident's Physician. A finding that the complaint allegations “Resident's medication is missing” 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.

No deficiencies cited during today’s inspection.

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

LIC9099 (FAS) - (06/04)

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