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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:36:16 PM


Document Has Been Signed on 06/02/2022 12:36 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: 6DATE:
06/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:42 AM
MET WITH:Diandra Chadwick (Staff)TIME COMPLETED:
12:51 PM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra arrived unannounced and was greeted by staff Leah Perry, staff Diandra Chadwick arrived later. Licensee was not able to come to the facility but was available by phone and gave authorization for staff to sign the report. The purpose of this visit is to find out who the new administrator of the facility is, as no paperwork has come into the Licensing office after LPA received a notification from the Licensee that and the prior facility administrator, Josh Horn, no longer worked at the facility as of 1/30/22.

Based on interviews conducted with Licensee that facility is in the process of a change of ownership, the applicant has a valid Administrator Certificate. Although, individual has been fingerprinted they are not associated to the facility roster yet. Licensee agreed to submit required documentation that is needed for the change of administrator: LIC 215 Applicant Information, LIC 308 Designation of Facility responsibility (designation of who is the administrator), Administrator Certificate, First Aid Certificate, Administrator Resume, LIC 500 Personnel Report, LIC 501 Personnel Record, Copy of Personal ID, Copy of Board of Directors' Resolution meeting minutes signed (required for all corporations). Currently, the facility has not submitted change of administrator documentation, and at the present time, this facility has no active administrator on file. LPA had been at the facility and had left a report requesting documentation needed, with details of the forms required to complete the change. Licensee agrees to designate another interim Administrator with an active certificate

The Northern California/Adult Program Regional Office has scheduled an Informal meeting with Licensee to follow up on areas of concerns.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
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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Document Has Been Signed on 06/02/2022 12:36 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: 06/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/03/2022
Section Cited

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87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator.This requirement has not been met as evidenced by:
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Based on LPA observation, records review and interview with Licensee, the facility did not ensure to have an active administrator for the facility after prior Administrator left on 1/30/22 which poses an immediate risk to the health and safety of 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: 06/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/02/2022
LIC809 (FAS) - (06/04)
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