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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 08/29/2024
Date Signed: 08/29/2024 03:17:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240724140551
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:
08/29/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lisa DiBartolo (Administrative Assistant)TIME COMPLETED:
03:32 PM
ALLEGATION(S):
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-Staff did not dispense medication to resident as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrative Assistant Lisa DiBartolo.

Regarding allegation of staff did not dispense medication to resident as prescribed. Per Reporting Party, R1 had prescription orders for scheduled doses of Morphine and Haldol, but administrative assistant refused to provide R1 with these medications unless R1 can ask for them. Also, on 04/22/2024, administrative assistant staff refused to give R1 their morning dose of Seroquel, which they were supposed to receive twice per day at no set time. Upon noticed of the missing dose, the reporting party approached administrative assistant, but they were told that R1 was asleep when they passed the rounds of medications for that morning and they refused to give it to R1 once they woke up, even though hospice advised administrative assistant to assist R1 with the medication.
Continues on LIC9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20240724140551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/29/2024
NARRATIVE
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Continued from LIC9099...

There were other incidents where the reporting party have observed frequently crushed R1’s time released Metoprolol, which could have killed R1. Per reporting party, staff was also observed R1 chewing extra-strength Tylenol after it was dispensed to resident. Based on interviews conducted with outside party, it was revealed that an outside agency was concerned regarding medications were properly given to R1 as prescribed by their doctor. LPA obtained hospice records confirming concerns regarding medication administration. Regarding crushing medication incidents, hospice records confirmed that as of 4/7/24, R1 received a physician’s verbal order to crush medications and on 4/10/24, R1’s physician followed up with a written doctor’s order allowing facility staff to crush medications and give with small amount of food or on a teaspoon. On 4/22/24 at 5:36pm, hospice records revealed that R1 did not receive their morning dosage of Seroquel, the hospice nurse spoke with staff who stated that R1 is on schedule to have Seroquel 150mg at 8am and 5pm, so they could not give it late, the facility will need the order to be changed and its medication was not given. Hospice nurse explained staff that the order indicates twice daily, but staff created dosing schedule. Order obtained supports twice daily with no time indicate. Therefore, facility staff did not dispense medication to resident as prescribed per doctor’s order. Based on facility records of Medication Administration Records dated 4/22/24 confirmed that Seroquel medication was not given to resident. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D. Appeal Rights Given. **Immediate Civil Penalty assessed in the amount of $250 for repeated violation within 12 months.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/24/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240724140551

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:
08/29/2024
UNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Lisa DiBartolo (Administrative Assistant)TIME COMPLETED:
03:32 PM
ALLEGATION(S):
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-Staff did not inform resident's authorized representative of a change in resident's condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrative Assistant Lisa DiBartolo.

The Department received an allegation of staff did not inform resident's authorized representative of a change in resident's condition. On 3/30/24 staff have notified resident’s responsible party that R1 had been using a wheelchair for the past two weeks and on 03/24/2024, 911 was called to transport R1 because R1 was dizzy and not able to walk. The Reporting party states that the facility did not informed R1’s responsible party timely that resident’s ambulatory status has been declining to the point that they need the wheelchair. Also, there was another incident that have occurred back in November 2023 where the facility staff failed to notify R1’s responsible party until next morning at around 10am that R1 was transported to the hospital. Based on records review of R1’s progress notes from Sutter Health and incident report logs from the Department, it was confirmed that both incidents occurred.
Continues on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 21-AS-20240724140551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/29/2024
NARRATIVE
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Continued from LIC9099A...

However, according to R1’s responsible party, they were not notified by the facility staff about the change of ambulatory status noticed on 3/30/24. The responsible party indicated that on 3/24/24, R1 was not observed needing to use a wheelchair to ambulate and the administrative assistant was refusing that R1 received hospice services, because they did not consider that R1 was dying. Although, R1’s physician report dated 2/6/24 indicates that R1 have a non-ambulatory status including dependency of mechanicals aids such as walkers and wheelchairs. On 4/2/24, the Department received an incident report informing that on 3/30/24 at 9pm, R1 was not doing well, facility staff contacted emergency medical responders (EMS) who assessed R1 and spoke with their responsible party who did not want R1 to go to the hospital, R1 did not go to the hospital, their responsible party notified R1’s physician and referral for hospice services was given. Hospice records revealed that on 3/30/24 staff stated that R1 has been ambulating independently. However, R1’s responsible party differs stating that R1 has been needing to a wheelchair occasionally for past few weeks. Hospice nurse observed R1 getting up independently and walk back to their room when hospice chaplain was visiting that afternoon. Hospice records indicated that on 4/1/24, R1 was observed ambulating independently through the facility. On 4/17/24, R1 was observed walking around the facility holding onto caregiver’s hand. Although, it is unclear to determine whether the facility staff have informed R1’s responsible party about both incidents. It was revealed that R1’s responsible party were aware of R1’s rapid health declining since 2020 due to progressive cognitive primarily in memory and executive function more than visuospatial. During interviews conducted with R1’s responsible party on 8/8/24 such information was also confirmed. A finding that the complaint allegation of staff did not inform resident's authorized representative of a change in resident's condition is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20240724140551
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/30/2024
Section Cited
CCR
87465(c)(2)
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Type A- 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Licensee agrees to retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications will be dispensed to residents in care as prescribed by their physician daily. Licensee to submit the updated plan to CCL by POC due date to clear the citation. **Immediate Civil Penalty assessed in the amount of $250.
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Based on interviews with staff and records review Licensee did not ensure proper management of medication by staff did not give R1’s their dosage of Seroquel 150mg as prescribed by their physician’s, which poses an immediate risk to the health & safety of residents in care.
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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: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC9099 (FAS) - (06/04)
Page: 5 of 5