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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 08/17/2023
Date Signed: 08/17/2023 03:59:31 PM


Document Has Been Signed on 08/17/2023 03:59 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:
08/17/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:29 PM
MET WITH:Casie Guerrero (Lead staff)TIME COMPLETED:
03:50 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 Analysts (LPAs) Cuadra and Coppo arrived unannounced to conduct a case management to follow up on the Pre licensing process initiated by a change of ownership. LPA was greeted by Cassie Guerrero (Lead Staff). Current Administrator Anna Botones was unable to come to the facility, but were available by phone and gave authorization for staff to sign the report. LPAs were unable to pull LIC809 report due to technical issues and Administrator were notified about deficiencies found during the visit.

At approximate 1:45pm LPAs/Lead staff observed a couple mattresses, bed furniture and bed rails obstructing the back exit door located in shared bedroom #3. Based on interviews conducted with staff, the furniture had been there for days and it's supposed to be discarded. However, no date was provided by Administrator.

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.

Administrator acknowledged the citation and agreed to sign the report once LPA drafted the report and send it via email for signature.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 08/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
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 08/17/2023 03:59 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: 08/17/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/18/2023
Section Cited
CCR
87307(d)(6)

1
2
3
4
5
6
7
87307 Personal Accommodations and Services (d) The following space and safety provisions shall apply to all facilities:
(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement has not been met:
1
2
3
4
5
6
7
Administrator agrees to clean the passageway area and remove items that are representing an immediate hazard to exit located at the back yard in shared bedroom#3. Administrator will submit photo verification that the passageway is free of obstruction to CCL by POC date.
8
9
10
11
12
13
14
Based on LPAs/lead staff observation and interviews with staff, the facility did not ensure that back exit door located at shared bedroom#3 passageway were kept free of obstruction which is an immedite risk to the health & safety of residents in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: 08/17/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/17/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2