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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 03/14/2022
Date Signed: 03/14/2022 11:13:21 AM


Document Has Been Signed on 03/14/2022 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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:
03/14/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Alain Serkissian (Licensee)TIME COMPLETED:
11:28 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management Legal/ Non-compliance inspection to this facility and was greeted by staff, Lorie Vasold. Licensee, Alain Serkissian arrived later. Licensee informed LPA that staff, Diandra Chadwick is working on Administrator Certificate.

LPA/staff conducted a walk through the facility. At approximate 9:42am LPA/staff pulled the alarm that sounded and stated room number that needed help and after five minutes the alarm was reset by staff by the office without a staff that would come and help. LPA/staff tried a second time in different room at approximate 9:53am and once again no staff came to help. Licensee informed LPA that the facility conducted a 2-day In-service training with all staff. LPA/Licensee discussed the importance of the call light stations were to be followed by staff. 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/Licensee reviewed staff schedule for the month of March 2022 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 56 to 64 hours annual of training including care of persons with Dementia.

Continues on LIC809C...
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496800941
VISIT DATE: 03/14/2022
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Continued from LIC809...

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/Licensee observed residents who appeared to be safe, healthful and comfort.

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 provided LPA 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/Licensee 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 87303(i)(1)(A).
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 03/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 03/14/2022 11:13 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496800941

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/15/2022
Section Cited

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87303 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:
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Based on LPA/Licensee observation and interviews. Facility did not ensure that resident's rooms had a signal system that was working properly. LPA/staff tested twice, pulled alarms and staff were not alerted which poses an immediate 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: 03/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3