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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 12/15/2022
Date Signed: 12/15/2022 11:57:54 AM


Document Has Been Signed on 12/15/2022 11:57 AM - 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: 5DATE:
12/15/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Cassie Guerrero (Lead Staff)TIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a Pre licensing Inspection initiated by a change of ownership. LPA was greeted by Cassie Guerrero (Lead Staff). Applicant Anna Botones and current Licensee Alain Serkissian were unable to come to the facility, but were available by phone and gave authorization for staff to sign the report. Applicant has applied for a Change of Ownership and there are currently 5 residents in care, no residents in hospice and residents with a Dementia diagnosis in care.

LPA/Lead staff initiated a tour of the facility at 9:45 am and made the following observations: The facility was clean and well organized. All exits unobstructed. Smoke; Carbon Monoxide, all current. First aid kit fully stocked. Resident bedrooms and bath appropriately furnished and clean.

Facility made conversions outside by the pool area without building permit or updated fire clearance. Constructed room used for storage. Facility is working on getting permit to be in compliance with regulation.

At approximate 10:00am LPA/Lead staff tested the hot water in resident's bathrooms at 124 and 125.1 degrees F which is not within allowable range of 105 to 120 degrees F.

At approximate 10:20am LPA/Lead staff observed Fire extinguisher was last serviced and charged on October 2021.

Deficiencies 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. Appeal rights given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
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 12/15/2022 11:57 AM - 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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/16/2022
Section Cited

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87202 Fire Clearance (a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire dpt...This requirement is not met as evidenced by:
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Administrator will contact the Fire Department to have fire extinguisher serviced. Administrator agreed to submit self-certification form as a proof of Correction (POC) that fire extinguisher have been serviced and charged by a fire extinguisher service company or the Fire Department by POC due date
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Based on observation, the Administrator did not comply with the section cited above in 3 out of 3 fire extinguisher was not serviced since October 18, 2021 which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
12/16/2022
Section Cited

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87303 Maintenance & Operation (e)Water supplies...shall be maintained... (2) Faucets used by residents...Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 and not more than 120 degree F. This requirement is not met as evidenced by:
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Facility to ensure that hot water temperature stays within Title 22 Regulations of not less than 105 degree F and not more than 120 degree F and will submit a self-certification stating that they will follow regulation.
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Based on Thermometer readings, Licensee did not comply with the section cited above where 2 of 2 sinks showed a hot water temperature of 124 and 125.1 F 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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 12/15/2022 11:57 AM - 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: 12/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/29/2022
Section Cited

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87305 Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement has not been met:
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Licensee & Administrator agrees to obtain building permit or remove any conversions and send self certification of the removal to CCL by POC due date.
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Based on LPAs record review and interview the faciltiy failed to obtain permit for conversions made in storage which poses a potential health and safety risk to clients 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: 12/15/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2022
LIC809 (FAS) - (06/04)
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