496800941-7-29-2021-21-AS-MCUA-C5E6ZQ-20210729211528

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 07/28/2021
Date Signed: 07/29/2021 09:15:52 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 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:	DATE:	07/28/2021
TYPE OF VISIT:	Office	UNANNOUNCED	TIME BEGAN:	10:01 AM
MET WITH:	Alain Serkissian (Licensee) and Josh Horn (Administrator)		TIME COMPLETED:	10:45 AM

NARRATIVE

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A Non-Compliance Conference was conducted today in the Rohnert Park Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were Licensing Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, Licensee, Alain Serkissian and Administrator, Josh Horn.

This Compliance Plan Conference is being conducted to discuss concerns identified by the Licensing Agency regarding to the operation of this facility including but not limited to: Complaint investigation that has been substantiated for prohibited condition and timely medical attention. Other concerns that have been observed during a post-licensing visit are:

- Timely Medical Attention: Facility failed to seek timely medical attention.

- Staffing: Facility didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs.

- 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.

- Observation of the Resident: Facility did not observe change of condition in resident after fall.

- Resident Records: Facility wasn't able to provide CCLD with resident's care notes for review.

- Reporting Requirements: Facility did not ensure that CCL was notified about incidents after falls occurred on 2019 and 2020 including resident with Prohibited Condition (StageIII) wound.
Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

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
	VISIT DATE: 07/28/2021

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Continued from LIC809...

The Regional Office will re-review progress made on Non-Compliance Plan of 2 years.

CCL has provided copies of the following Regulations: Title 22 Regulations #87465 Incidental Medical & Dental Care; #87705 Care of Persons w/Dementia; #1569 .269 (a)(5) Enumerated Rights; #87466 Observation of the Resident; #87506 Resident Records; #87211 Reporting Requirements.

Licensee agreed to do the following in order to bring the facility into compliance no later than the following dates:

1. Timely Medical Attention: Facility will ensure to seek timely medical attention for residents in care. Facility has submitted a plan of correction on March 10, 2021.

2. Staffing: Facility will have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. Facility has submitted a plan related to staffing for each shift on March 10, 2021. Licensee agreed to submit an updated LIC500 by August 6, 2021.

3. Enumerated Rights: Facility will ensure to follow up on resident’s needs after resident’s falls. Facility has submitted a plan of correction on March 10, 2021.

4. Observation of the resident: Facility will assess resident’s injuries after a change of condition or after a fall.

5. Resident Records: Facility will ensure that residents' files have all required documents on file and ready to be reviewed by CCLD. Facility will submit a plan of how they will ensure records are retained and safe from future destruction. Plan of future compliance to be submitted by August 6, 2021.

6. Reporting Requirements: Facility will ensure all incidents that threaten the safety of residents are reported to CCL per regulation. Facility will contact an outside vendor to conduct training for all staff on reporting requirements. Sign-in sheet for all staff trained to be submitted by August 6, 2021.

The licensee was informed that additional civil penalties are under review by the Department per Health and Safety Code 1569.49 (f) due to substantiated complaint # 21-AS-20201207072042.

There were no deficiencies cited at this time.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2021

LIC809 (FAS) - (06/04)

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