496803871-12-29-2022-21-AS-SHAN-CMKRME-20221229120837

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496803871
Report Date: 12/29/2022
Date Signed: 12/29/2022 12:08:48 PM

Document Has Been Signed on 12/29/2022 12:08 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 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: 5	DATE:	12/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Alain Serkissian, Administrator		TIME COMPLETED:	12:10 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) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection and met with Licensee, Alain Serkissian. Facility has 5 residents, 3 with dementia, and 1 resident under hospice care. LPA was greeted by staff who called Licensee arriving approximately 30 minutes later. LPA toured facility with Lead Staff Roxana at approximately 9:35am. Facility was a comfortable temperature and exits were free from obstructions. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Facility has at least two days of perishable and one week of non-perishable food. During inspection at 9:45 am LPA/Lead Staff observed kitchen sharps drawer lock broken (see LIC809-D). LPA observed that resident rooms were furnished per regulations. Facilities three bathrooms were equipped with non-slip floors and mats for safety and stocked with hand hygiene products. Water temperature tested at 105.6 degrees F, 113.7 degrees F, and 116 degrees F within acceptable range of regulation of 105 to 120 degrees F. Facility has space indoors and outdoors for resident activities. A violinist and piano player where entertaining residents during LPA’s visit. Fire extinguishers last serviced 10/18/2021, not within fire clearance regulation (see LIC809D). 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 residents in care. Medications are centrally stored and locked in a closet located in the kitchen hallway and inaccessible to residents. Facility maintains a 30 day supply of medication. Disaster Drills have been conducted quarterly with the last one being conducted in10/2022. Continue LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

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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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 CARNATION	FACILITY NUMBER: 496803871
	VISIT DATE: 12/29/2022

NARRATIVE

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Infection Control:
Facility has submitted a mitigation program plan and Infection Control Plan. Residents do not typically wear a mask while in the facility, but they do wear masks when in the community. LPA observed that staff were wearing masks during this visit. Facility has more than a 30 day supply of Personal Protective Equipment (PPE). PPE supplies are located in an accessible place for all staff.

In addition, facility has a designated area for visits. Residents have also available Zoom, Facetime, and telephone calls when contacting with family members and others. Staff had all PPE training required on file and have obtained N-95 fit testing.

LPA Hansen reviewed Licensing Information System (LIS) with Licensee who informed the facility phone needs to be changed to (707)820-1234 and add fax number. Licensee will submit LIC200 for request. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of current CPR & 1^st Aid certification for staff.

Administrator Certificate is for Alain Serkissian # 6011190740 Exp. 11/11/2022 (Pending as of 10/18/22)
Facility has a 100% COVID vaccination rate of staff.

The following deficiencies were observed (see LIC 809D) and 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. Exit interview conducted and appeal of rights provided. Appeal of Rights Given.

LPA Hansen is requesting Licensee to update and submit the following documents to CCL by 1/6/2023:

LIC 308 Designated

Articles of Corporation

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

LIC 9020 Register of Facility Client’s/Resident’s

Copy of Administrator Certificate

Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 12/29/2022 12:08 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 CARNATION	FACILITY NUMBER: 496803871
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87202(a)

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:
	Deficient Practice Statement
1 2 3 4	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.
	POC Due Date: 12/30/2022
	Plan of Correction
1 2 3 4	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 12/30/2022.

Type A

Section Cited

CCR

87705(f)(1)

87705(f)(1)Care of Persons w/Dementia - The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s) This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the Administrator did not comply with the section cited above in 1out of 1 kitchen drawers containing knives and other sharps, was witnessed by LPA/Lead staff to have broken lock, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 12/30/2022
	Plan of Correction
1 2 3 4	Licensee to ensure that all sharp objects and toxins are stored in a locked storage inaccessible to residents at all times.Licensee to fix lock on drawer containing sharp objects in kitchen and submit proof of correction. Licensee to also provide training of regulation for caregivers (with signed /dated) and submit both to CCL by EOB 12/30/2022.

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) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2022

LIC809 (FAS) - (06/04)

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