496800941-10-7-2021-21-AS-MCUA-C7KS6K-20211007133605

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 10/07/2021
Date Signed: 10/07/2021 01:36:25 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: 32	DATE:	10/07/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:49 AM
MET WITH:	Josh Horn (Administrator)		TIME COMPLETED:	01:46 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection and a case management-Incident-Legal/Non-compliance inspection to this facility. During today's visit LPA met with Licensee, Alain Serkissian and Administrator, Josh Horn. LPA conducted a Risk Assessment call with Administrator prior to the visit. LPA arrived at the facility and had their temperature checked and logged into a sign-in sheet. LPA observed that facility has posters on the front door indicating visitors about updated visitor's policy to protect residents in care. Once inside the facility, LPA observed that staff were wearing masks during this visit. LPA/Licensee conducted a walk-through of the facility and observed Covid-19 posters that included hand washing signs in restrooms. Facility was a comfortable temperature and exits were free from obstructions. Automatic hand sanitizer dispensers are located through the facility. Facility has multiple bathrooms that are kept stocked with hand hygiene products. Commonly touched surfaces are disinfected at least five times a day. Facility has designated an outdoor area for visitation. Facility has a designated isolation apartment on the facility premises for residents that need to isolate and is able to serve meals and deliver medications. Facility staff have been trained on PPE protocols but not all staff have been N-95 fit tested. Staff and residents are being monitored daily. However, facility does not document symptoms unless that they are experiencing any symptoms. LPA/Administrator discussed the importance of daily screening and documentation of symptoms. Facility maintains a 30 day supply of medication. Facility has a 100% vaccination rate of staff and residents. Facility is currently in the process of seeking for a place that can provide vaccine booster to coordinate with them to inoculate all residents and staff. Facility still conducts surveillance testing 25% staff every 7 days. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. Facility has more than a 30 day supply of Personal Protective Equipment (PPE) including masks, face shields, gowns and hand sanitizer. PPE supplies are located in an accessible place for all staff. 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: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: 10/07/2021

NARRATIVE

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Continues from LIC809...

Fire extinguishers were last inspected in September, 2020. Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 10/5/2021. Facility has submitted their Covid Mitigation Plan and approved on 8/2/21. LPA observed residents engaged in a group activity during inspection. Residents have access to alternative communications as phone calls and video calls with their families.

At approximate 10:30am LPA/Administrator tested call system and observed after five minutes there was no response. LPA/Administrator attempted to pull the code alert cord for another two locations. but system was not working and there were two locations were cords are missing. LPA/Administrator came back to office and Administrator informed LPA that monitor was off. LPA inquired when was the last time that the system was serviced and Administrator informed LPA that it was prior to Covid. Administrator will follow up with company that provides services of alert system to figure out how to print out a call system report to be able to obtain responses times. Administrator agreed to conduct all staff training on call system procedures [87303(i)(1)(A)]

LPA also followed 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 self incident reports and it appears that staff had been responding timely to medical emergencies.

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/Administrator reviewed staff schedule for the month of September 2021 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. LPA reviewed staff training records and most of staff has received an average of 63 to 71 hours annual of training including care of persons with Dementia.

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/Administrator conducted a tour through the facility and residents appeared to be safe, healthful and comfort.
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: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

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: 10/07/2021

NARRATIVE

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Continued from LIC809C...

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, R5 and R6) records and residents have been assessed for change of condition within the last 12 months per regulation.

CCR 87506 Resident Records - Facility wasn't able to provide CCLD with resident's care notes for review. Facility provided LPA with a new designed template to document daily resident's care notes including showering schedule, skin conditions, mental mood, out of the facility status and various notes. LPA/Administrator observed daily care notes document for each resident.

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.

LPA is following up on an incident received on 9/30/21 from Administrator regarding resident (R1). On 9/19/21 R1 was found by staff (S1) sitting down on the ground on front porch, S1 conducted range of motion and R1 revealed that their right leg was unable to be moved and it was swelling. S1 called 911 and R1 was transported to the Emergency Room at Sutter Hospital. Responsible parties and CCL were notified. R1 was diagnosed with a fracture and it was determined due to R1's age and condition to send them to a rehabilitation facility until they fully recover from fracture. During today’s visit LPA reviewed R1’s file including Physician’s report that included R1's plan of care after injury where the treatment does not include surgery.

Deficiencies are cited from the California Code of Regulations (CCRs), Title 22, Division 6, Chapter 8 and the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment. Appeal rights given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

Page: 3 of 5

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: 10/07/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(i)(1)(A)

Maintenance and Operation

(i) 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. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	This requirement was not met. Based on LPA/Administrator observation and interviews. Facility did not ensure that resident's rooms had a signal system that was operational or working properly. LPA/Administrator tested and pulled alarms and staff were not alerted which poses an immediate health and safety risk to residents in care.
	POC Due Date: 10/08/2021
	Plan of Correction
1 2 3 4	Administrator agreed to contact maintenance company to corrected issue and facility will conduct staff training on signal system timely responses and will submit proof of service to CCL by 10/8/21.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2021

LIC809 (FAS) - (06/04)

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