496804122-3-13-2023-21-AS-MCUA-CPVUXK-20230313155828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 03/13/2023
Date Signed: 03/13/2023 03:58:35 PM

Document Has Been Signed on 03/13/2023 03:58 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		FACILITY NUMBER:	496804122
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 29	DATE:	03/13/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Alex Varshavsky (Applicant)		TIME COMPLETED:	04:13 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) Marisol Cuadra arrived unannounced to conduct a Pre-Licensing Inspection and met with Applicant, Alex Varshavsky. Facility has a Dementia Care Program. Applicant has applied for a Change of Ownership at this location that currently has 29 residents in care. LPA/Lead Staff initiated a tour of the facility and made the following observations: Facility is a one story residence with four single resident bedrooms (room#1, 6, 9 and 12), fifteen shared resident bedrooms (room #2, 3, 4, 5, 7, 8, 10, 11, 14, 15, 16, 17, 18, 19 and 20), six bedridden might be bedridden, 13 bathrooms, two office areas, one kitchen area, one dining room, two activity rooms and common areas. All resident rooms are furnished per regulation. Bathroom showers have non-skid shower floors/mats and grab bars. Water temperature in tested bathrooms read at 109, 111 and 116.8 degrees F which is within regulation of 105 & 120 degrees F. Facility has sufficient items used for cooking and eating. Perishable and non-perishable foods observed per regulation. Facility front porch has an area for visiting and activities. Facility received an approved fire clearance dated November 16, 2022 that allows for 28 non-ambulatory residents and 6 bedridden resident. Fire Extinguishers were last serviced January 2023. Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 2/7/23. Facility has a locked perimeter. Facility has lighting in hallways. LPA confirmed that contents of the facility First Aid Kit were sufficient and that facility has emergency lighting in case of a power outage. Emergency food and water supplies are stored in the kitchen pantry. Last disaster drill was conducted on February 2023. Continued on LIC809C...

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

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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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	FACILITY NUMBER: 496804122
	VISIT DATE: 03/13/2023

NARRATIVE

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Continued from LIC809...

LPA observed required postings including the CCL Complaint Poster, Long Term Care Ombudsman Poster, Resident's Rights, and the rights to Resident and Family Councils.

Medications and files are secured in a locked cabinet in the office area. LPA and Applicant discussed that all resident files would need to be updated upon Licensure. LPA confirmed that Applicant signed up for the Guardian and Provider Information Notices (PINs) that the Department sends out.

During today's inspection, LPA/Lead staff observed all resident's rooms auditory alarm system were not operational or working properly. Also, it was observed exits from resident's rooms (room# 2, 4 and 6) were obstructed. Lead staff removed furniture and objects that were blocking the exit immediately. Deficiencies observed by LPA are cited on current license #496800941:

Component III was conducted with Applicant. LPA will submit copy of the facility report to the Centralized Application Unit and inform of citations, exits obstructed and auditory alarms not working. Per Applicant/current Administrator the facility has a hospice waiver approved for 6 residents; LPA will inquire about hospice waiver on file for this facility. LPA to conduct subsequent pre-licensing inspection after POC's are cleared.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 03/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2023

LIC809 (FAS) - (06/04)

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