496803871-8-31-2020-21-AS-MCUA-BSZP72-20200831110314

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803871
Report Date: 08/31/2020
Date Signed: 08/31/2020 11:03:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	MIRABEL LODGE AT CARNATION		FACILITY NUMBER:	496803871
ADMINISTRATOR:	SERKISSIAN, ALAIN		FACILITY TYPE:	740
ADDRESS:	6992 MIRABEL RD		TELEPHONE:	(707) 953-4600
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	6	CENSUS: 3	DATE:	08/31/2020
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Josh Horn (Administrator)		TIME COMPLETED:	10:43 AM

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 conducted the Post Licensing inspection via video conferencing due to Covid19 precautions with Administrator, Josh Horn and obtained email address (mirabellodge@yahoo.com) to send LIC809 and requested signed copy to be emailed back to LPA before 9/4/20. This tele-visit is intended to ensure that the residents were also able to safely return to the home after being evacuated as a result of a wildfire in the area. Facility was not required to evacuate; but, Licensee decided to do so due to the health and safety risk that the fire presented to residents in the home. Residents were evacuated on 8/19/2020 and were given clearance to return on 8/26/2020 by Forestville Fire Department. Based on interview with Administrator there were no incidents directly related to the evacuation or repopulation of the residents and there is no known damage to the home or the property. Administrator conducted a walk through via video conferencing and no visual signs of fire damage. Per Administrator, the facility was cleaned by facility staff prior to repopulation and all resident bedding replaced. Facility does not has a waiver for most meals to be made at Licensee's other facility and transported. Facility has at least two days of perishable and one week of non-perishable food available for breakfast and snacks. LPA observed that resident rooms were furnished per regulations and three bathrooms were equipped with non-slip floors and mats for safety. Water temperature tested at 108 and 112 degrees F within regulation. Facility has space indoors and outdoors for resident activities. LPA observed required postings (LTCO, CCL Complaint poster, visitor policy, employee rights and personal rights). in addition to COVID-19 required visitation postings. Facility has a sanitation station set up at the entrance to the facility in order to comply with Covid-19 precautions. Facility are screening staff or essential visitors for symptoms. The facility staff was observed wearing mask during the virtual tour of main entrance, doors, common areas, dining rooms and kitchen area. LPA reviewed with Licensee PIN 20-23. Facility provides assistance with family communication via telephone or video call. Continues on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MIRABEL LODGE AT CARNATION	FACILITY NUMBER: 496803871
	VISIT DATE: 08/31/2020

NARRATIVE

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Fire extinguisher was last serviced 12/13/2019. Fire clearance granted by Forestville Fire Protection District on 10/4/2019, granting capacity of 6 and all non-ambulatory. Power and all other utilities including cable and phone were observed to be working. The smoke alarms are hardwired and observed operational during inspection. Carbon Monoxide Detector were tested and operational. Toxins were locked in the laundry room and inaccessible to clients in care. Medications is centrally stored and locked in a cabinet located in the hallway and inaccessible to clients.

Resident and staff records are maintained. LPA was unable to conduct a thorough review of records but did confirm that each staff has an active First Aid/CPR Certificate. Licensee agreed to submit staff's proof of annual training to LPA. Licensee completed new Admission Agreements for all residents. A Centrally Stored Medication Log is maintained. Administrator ensured best practices for PPE usage, COVID prevention and COVID surveillance testing for all staff and clients during their relocation.

Administrator agreed to revise and submit updates to the disaster/evacuation plan. LPA confirmed that Administrator had received a copy of PIN 20-28-ASC (Emergency Resident Transfers During the Coronavirus Disease (COVID-19) Pandemic) for reference.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 08/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2020

LIC809 (FAS) - (06/04)

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