496800941-12-6-2021-21-AS-MCUA-C9FUU6-20211206145300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 12/06/2021
Date Signed: 12/06/2021 02:53:09 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: 34	DATE:	12/06/2021
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Alain Serkissian (Licensee) and Josh horn (Administrator)		TIME COMPLETED:	03:03 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 case management Legal/ Non-compliance inspection to this facility and met with Licensee, Alain Serkissian and Administrator, Josh Horn. LPA conducted a Risk Assessment with staff. LPA received updated information regarding the call system that needs to be replaced. Per Administrator, the programmer is building a new system, call light stations will be the same. However, there is no date when the system will be completely updated. In the meantime, staff are conducting more frequent round checks to residents in care. LPA reviewed staff schedules for the month of December 2021 that appears to be sufficient to meet residents in care needs. 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 December 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 (S1, S2, S3, S4, S5 & S6) has received an average of 62 to 70 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 observed residents who appeared to be safe, healthful and comfort. Continues on LIC908C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

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: 12/06/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 12/07/2021 Section Cited	1 2 3 4 5 6 7	87466 Observation of the Resident - The licensee shall ensure that residents are regularly observed for changes in physical…& that appropriate assistance is provided when such observation reveals unmet needs...This requirement has not been met as evidence by:
	8 9 10 11 12 13 14	Based on interviews conducted with Administrator & Licensee, records review revealed that facility have not assessed 6 out 6 residents (R1, R2, R3, R4, R5 & R6) for a change of condition within the last 12 months per regulation which poses an immediate risk to the health and safety of the residents in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC809 (FAS) - (06/04)

Page: 2 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, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496800941
	VISIT DATE: 12/06/2021

NARRATIVE

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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, R5 and R6) records and residents have not been assessed for change of condition within the last 12 months per regulation. Per Administrator, the facility is in the process of implementing a new electronic system to keep track of resident's care services plan and inform responsible parties of any changes of condition of residents in care.

CCR 87506 Resident Records - Facility wasn't able to provide CCLD with resident's care notes for review. Facility provided a notebook with supplemental resident's care notes along with 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.

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. ***Civil penalties are being assessed in the amount of $250 for repeated violation CCR 87466.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2021

LIC809 (FAS) - (06/04)

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