496800941-6-13-2022-21-AS-MCUA-CFCU29-20220613151135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 06/13/2022
Date Signed: 06/13/2022 03:11:45 PM

Document Has Been Signed on 06/13/2022 03:11 PM - 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 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: 33	DATE:	06/13/2022
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME BEGAN:	12:38 PM
MET WITH:	Alain Serkissian (Licensee)		TIME COMPLETED:	03:26 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 was greeted by staff, Kassandra Guerrero, individuals (I1) and (I2) were present in the facility and were not associated yet. Licensee, Alain Serkissian arrived later. LPA learned through interviews with staff that individuals (I1 and I2) had been working providing care and supervision to residents in care for one day and has not been associated to the facility yet. LPA informed Licensee that individuals (I1 & I2) are fingerprint, but they are not associated to the facility and should never be working and providing care to residents prior to a criminal record clearance or exemption. LPA/Licensee conducted a walk through the facility. At approximate 2:00pm LPA/Licensee pulled the alarm that sounded and stated room number that needed help and after a couple minutes the staff came to help resident. LPA was following 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. 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 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. 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: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

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: 06/13/2022

NARRATIVE

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Continued from LIC809...

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 June 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 62 to 73 hours annual of training including care of persons with Dementia.

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.

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 $100 per day for allowing a person to work, reside or volunteer in the facility without a fingerprint clearance exemption.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/13/2022 03:11 PM - 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: 06/13/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/14/2022 Section Cited	1 2 3 4 5 6 7	87355 Criminal Record Clearance (e)All individuals... shall prior to working, residing or volunteering in a licensed facility: (1)Obtain a California clearance or a criminal record exemption as required by the Dpt...This requirement is not met as evidenced by:
	8 9 10 11 12 13 14	Based on LPA observation, record review & interview with Licensee did not ensure to obtain a criminal record clearance for individuals (I1 & I2) prior to work, reside or provide care to residents in care which poses an immediate health, safety and personal rights risk to residents in care. ***Civil Penalty is being assessed for the amount of $100 per day.	8 9 10 11 12 13 14
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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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/13/2022

LIC809 (FAS) - (06/04)

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