496803416-2-3-2023-21-AS-MCUA-CNPSQZ-20230203130534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:05:44 PM

Document Has Been Signed on 02/03/2023 01:05 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 MEADOW		FACILITY NUMBER:	496803416
ADMINISTRATOR:	BOTONES, ANNA KARINA P		FACILITY TYPE:	740
ADDRESS:	5161 OAK MEADOW DRIVE		TELEPHONE:	(707) 800-7364
CITY:	SANTA ROSA	STATE: CA	ZIP CODE:	95401
CAPACITY:	6	CENSUS: 5	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:07 AM
MET WITH:	Anna Botones (Administrator)		TIME COMPLETED:	01:19 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 unannounced to conduct an Annual Required inspection and met with Administrator Anna Botones. The inspection is focused on the Infection Control procedures. During today's visit LPA/Administrator toured the facility and observed the following: Facility has COVID-19 posters throughout that include hand washing signs in bathrooms. Facility was a comfortable temperature and exits were free from obstructions. Hand sanitizer is located throughout common areas of the facility. Staff had masks on during this visit. Commonly touched surfaces are disinfected at least twice per day. Facility continues to screen staff and residents and maintains documentation. Facility has a designated visitation area outside and is allowing for visitation in resident rooms per CCL guidance. Staff continue to receive training on infection control and donning and doffing of Personal Protective Equipment PPE and N95 fit tested. Facility has more than a 30 day supply of PPE, medication and incontinence care supplies. Facility has submitted their Emergency Disaster Plan, Infection Control Plan and Mitigation Plan. Fire extinguisher is fully charged and serviced within the last year. LPA confirmed that facility is no longer requiring vaccination verification per recent guidance. LPA observed a couple ants in the common area next to the sliding door and also observed treatment for the ants (See LIC 9102). Administrator is still in the process of obtaining a building permit to update conversions made to the facility to update their fire clearance sketch. At approximate 12:00pm LPA/Administrator observed that facility liability Insurance certificate #NALCA20201174422 expired as of 1/22/23. On 12/30/22 the facility submitted their liability insurance certificate to CCL due to a process of a change of ownership and Licensee agreed to update their liability insurance timely if the change of ownership was not completed by 1/22/23. As of today, the facility still needs to correct items prior to complete the change of ownership process and obtain a new license. Licensee agreed to provide an updated liability insurance certificate to CCL to be back in compliance with Title 22 regulations. Administrator also agreed to submit updates of the following documents by 2/17/2023: LIC 308 Designated of responsibility, LIC 500 Personnel Summary and LIC 610 Emergency Disaster Plan (review and update if changes) 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. Exit interview was conducted with Administrator and a copy of report was given.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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 02/03/2023 01:05 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: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.605

1569.605 Liability Insurance - On and after July 1, 2015, all residential care facilities for the elderly, shall maintain liability insurance covering injury to residents and guests. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, records review & interview with Administrator, the licensee failed to keep an up to date liability insurance certificate as proof of liability insurance which poses a potential health & safety risk to residents in care.
	POC Due Date: 02/17/2023
	Plan of Correction
1 2 3 4	Licensee to ensure that facility maintains liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate. Licensee agreed to obtain Liability Insurance which indicates the minimum amount of insurance, expiration date (can't be expired), & liability insurance certificate number in order to clear this deficience licensee must provided CCL with COPY OF CERTIFICATE OF LIABILITY INSURANCE by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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