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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 06/03/2022
Date Signed: 06/03/2022 01:32:24 PM


Document Has Been Signed on 06/03/2022 01:32 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: 0DATE:
06/03/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Alain Serkissian (Licensee)TIME COMPLETED:
01:30 PM
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An office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra and Licensee Alain Serkissian. The purpose of the office meeting was to discuss areas of concerns regarding the new application that needs to be submitted to CCL and noticed to residents in care. After today's discussion, License is in acknowledge that he is responsible for the operation until new application is approved and issued.

Items addressed in today's meeting include but are not limited to patterns and trends in the areas below:

· Reporting Requirements of facility sale were not notified to CCL.
· Licensee and involvement in facility operation including lack of hire of new Administrator after prior Administrator no longer worked as of 1/30/22.

Documents requested during informal meeting to be submitted to CCL by June 6, 2022:

· Licensee will submit required documentation of a qualified Administrator with an active Administrator Certification associated to the facility.
· Licensee will submit an updated LIC500 indicating 24/7 staff coverage.
· Licensee will submit control of property or active property lease agreement.
· Licensee will submit a copy of written notification to residents in care about change of ownership.

No deficiencies cited during today's office meeting.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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