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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 02/18/2022
Date Signed: 02/18/2022 03:04:55 PM


Document Has Been Signed on 02/18/2022 03:04 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 AT OAK MEADOWFACILITY NUMBER:
496803416
ADMINISTRATOR:HORN, JOSHFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(707) 800-7364
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 5DATE:
02/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:09 PM
MET WITH:Diandra Chadwick (staff)TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced Annual Required – 1 yr. Infection Control inspection and was greeted by staff (S1) who were present and providing care at the facility and was not associated to the facility Personal Report/Roster in Guardian. Staff, Diandra Chadwick and Kassandra Guerrero arrived later, stated that S1 worked at the other facility, LPA confirmed that S1 was associated to other facility. Staff contacted CCL office to associate staff to this facility and understand that they should not allow a person to work, reside or volunteer in the facility without a fingerprint clearance or exemption. Immediate Civil Penalties are being assessed in the amount of $500 due to staff not being associated to the facility. LPA conducted a Risk Assessment with staff at entry. LPA/staff reviewed PIN 22-05, PIN 22-06, PIN 22-07 and PIN 22-09.

LPA arrived at the facility and did not have their temperature checked and logged into a sign-in sheet. LPA observed that staff were wearing masks during this visit. 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/staff 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 three 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 and have been N-95 fit tested. Records review indicated that residents were not being monitored daily since January, 2022. LPA/staff discussed the importance of daily screening and documentation of symptoms. Facility maintains a 30 day supply of medication.

Continues on LIC809C...

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MIRABEL LODGE AT OAK MEADOW
FACILITY NUMBER: 496803416
VISIT DATE: 02/18/2022
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Continued from LIC809...

Facility has a 100% vaccination rate of staff and residents. All residents are boosted and staff are in the process to get boosters. 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. Facility has submitted their Covid Mitigation Plan and approved on 8/2/21. Residents have access to alternative communications as phone calls and video calls with their families.

Staff agreed to submit the following documents by 2/25/22: Designation of Responsibility (LIC308), Liability Insurance, Personnel Report (LIC500) and Emergency Disaster Plan (LIC610E).

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. Immediate Civil Penalties are being assessed in the amount of $500 due to staff not being associated to the facility.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 02/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 02/18/2022 03:04 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 AT OAK MEADOW
FACILITY NUMBER: 496803416

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87468.1(a)(2)
Personal Rights of Residents in all Facilities
(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews with staff, Facility did not ensure the personal rights of persons in care to safe & health accommodations. Facility is not screening, documenting staff, residents for Covid19 symptoms to prevent the spread of the virus and to be in compliance with CCL guidelines which poses/posed an immediate health, safety or personal rights risk to persons in care.

POC Due Date: 02/19/2022
Plan of Correction
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Licensee/staff will ensure Personal Rights of residents are maintained. Facility agrees to submit proof of training for all staff to conduct screening and documenting for Covid19 symptoms to CCL by close of business 2/19/2022.

Type A
Section Cited
CCR
80019(e)(2)
80019 (e)(2) Criminal Record Clearance. All individuals subject to a criminal record review shall, prior to working, residing or volunteering in a licensed facility, request a transfer of a criminal record clearance.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs record review and interview with staff, S1 is not associated to this facility which is an immediate health and safety risk to clients in care.
POC Due Date: 02/19/2022
Plan of Correction
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Staff called and will fax CCL required documents to transfer S1's prints to this facility by 2/19/2022. **Civil Penalty assessed in the amount of $500 due to S1 not being associated to the facility.


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: 02/18/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3