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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 07/16/2024
Date Signed: 07/16/2024 10:36:04 AM


Document Has Been Signed on 07/16/2024 10:36 AM - 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 LODGEFACILITY NUMBER:
496804122
ADMINISTRATOR:VARSHAVSKY, ALEXANDERFACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: 28DATE:
07/16/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Lisa DiBartolo (Administrative Assistant)TIME COMPLETED:
10:50 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to follow up on an incident report dated 7/13/24 and SOC341 dated 7/15/24. LPA met with Lisa DiBartolo (Administrative Assistant).

Per incident report, on 7/13/24 resident (R1) approximately at 4:15pm went in another resident's (R2) room, staff redirected R1 to leave the room, but R1 was aggressive and hit R2 twice on their back and attempted to hit staff. Facility staff called 911 and EMTs determined that R1 needed further assessment at the hospital. Per discharge documents provided by the facility, R1 was seen for altered mental status and discharged with a diagnosis of hypernatremia, which is an electrolyte disorder. There were no new or change of medications order. Responsible parties were notified.

During today's visit, LPA have reviewed R1's physician report dated 3/12/24, who has a diagnosis of Dementia. After this incident, the facility have developed a plan of action including assessment of R1's behavior, communication and engagement of their responsible parties along with facility staff, implemented person-centered care to meet R1's needs, provide additional staff training including managing techniques, perform continuous evaluation of the effectiveness of implemented strategies. LPA was also provided with written request submitted by the facility to R1's physician dated 7/10/24 at 4:59pm, 7/11/24 at 1:12pm and 7/15/24 at 9:33am requesting medication review and possible adjustment to address R1's aggressive behavior without receiving any response from their physician as of today yet. LPA will review documentation received to determine if further action is needed.

No deficiencies cited during today's visit. Exit interview was conducted with Administrative Assistant and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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