<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 06/28/2022
Date Signed: 06/28/2022 03:16:59 PM


Document Has Been Signed on 06/28/2022 03:16 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:BOTONES, ANNA KARINA PFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(707) 800-7364
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 6DATE:
06/28/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:07 PM
MET WITH:Ilda Estrada (staff)TIME COMPLETED:
03:08 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 arrived at the facility for the purpose of conducting an unannounced Case Management visit and follow up on information received about change of ownership of this facility. LPA was greeted at the door by staff who was observed not wearing a mask and did not screened LPA for symptoms of Covid19. Upon entry, staff contacted Administrator, Anna Botones and Licensee, Alain Serkissian. However, LPA waited for over an hour and neither the Licensee nor the Administrator were able to come to the facility and Administrator was available over the phone and an hour in a half away, but gave authorization to staff to sign the report. LPA will raise this issue to management to discuss further actions.

During today's visit, LPA learned residents and staff are aware of change in administrator. A change in ownership package have not been submitted yet. LPA observed the residents in care at the facility. LPA observed one facility staff on duty assisting the residents. Facility was at a comfortable temperature; LPA observed most of the residents were in the living room.

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. A copy of the report was provided and Administrator was notified via phone about citations.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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 2


Document Has Been Signed on 06/28/2022 03:17 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: 06/28/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/29/2022
Section Cited

1
2
3
4
5
6
7
(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:
8
9
10
11
12
13
14
Based on observations & interviews licensee did not ensure to protect the personal rights of clients in care to receive safe & healthful accommodations & engaged in conduct inimical to the health, welfare, safety of clients in care, Licensee did not ensure S1 was wearing mask as reflected in facility's mitigation plan & current CCL requirements.
8
9
10
11
12
13
14
Type A
06/29/2022
Section Cited

1
2
3
4
5
6
7
Administrator Qualifications and Duties- 87405(d)(2) The administrator shall have the qualifications specified in Sections 87405(d)(1) through (7). If the licensee is also the administrator, all requirements for an administrator shall apply: (2) Knowledge of and ability to conform to the applicable laws, rules and regulations. This requirement is not met as evidenced by:
8
9
10
11
12
13
14
Based on LPA's observations, staff did not screen the LPA when having them enter the facility or at any time once inside the facility, the licensee did not comply with the section cited above in the required screening of a visitor, which poses an immediate health, safety and/or personal rights risk to persons in care.
8
9
10
11
12
13
14
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: 06/28/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2