496804122-6-23-2023-21-AS-MCUA-CT3RAJ-20230623125114

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 06/23/2023
Date Signed: 06/23/2023 12:51:31 PM

Document Has Been Signed on 06/23/2023 12:51 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:	06/23/2023
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Diandra Chadwick (Lead Staff)		TIME COMPLETED:	01:06 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) Cuadra arrived unannounced to conduct a post-licensing and Non-Compliance inspection. LPA met with Lead Staff, Diandra Chadwick. Licensee, Alex Varshavsky was not able to come to the facility, but was available by phone and gave authorization for lead staff to sign the report. The facility has residents receiving hospice services and residents with a diagnose of Dementia. LPA observed residents were participating in an exercise activity. Upon arrival, LPA confirmed with Lead staff that they are following current Covid19 and masks guidance. Facility is a one story building and have 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. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. LPA/lead staff pulled alert codes and staff responded in a timely manner. Fire panel was last inspected 07/2022. Last disaster drill was conducted on April 10, 2023. Exits and walkways were free from obstructions. Exit alarms were working properly. LPA observed required postings. Facility had sufficient perishable and non-perishable food. Facility front porch has an area for visiting and activities. Facility has first aid kit which was found to be appropriate during the Post-Licensing inspection. Emergency food and water supplies are stored in the kitchen pantry. All resident’s bedrooms have lighting & appropriate furnishings, and resident’s beds were outfitted with mattress pads as required by Title 22 Regulations. 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: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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: 06/23/2023

NARRATIVE

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Continued from LIC809...

Bathrooms had necessary grab bars and non-slip mats. Medications were centrally stored and secured. Hoyer lift machine is working properly. LPA observed activity calendar and weekly dated menu. LPA reviewed 10 residents and 10 staff files. Residents have current medical assessments and care plans. Staff records indicated that CPR/1st aid and received required annual training hours. Administrator certificate for Alex Varshavsky # 6052513740 expires on 7/15/2023.

At approximate 9:00am LPA/Lead staff toured building, grounds and found missing face cover plate in room# 7, bathroom in room #6 has an out of order sign, there are two drawers missing in shared bathroom for room# 4 and 5.

At approximate 9:30am LPA/Lead staff observed hot water temperature measured at 123.8, 118.6, 121.6, 122.4, 108.1, and 127.9 degrees in resident's bathrooms which are not within regulation.

At approximate 10:00am LPA/Lead staff observed that admission agreements were not updated after Change of Ownership. Per Lead Staff, they will create an addendum including the use of surveillance cameras in common areas and will have residents and their responsible parties sign them.

LPA followed up on items to ensure compliance with Non-Compliance Conference dated 7/28/21:

CCR 87211 Reporting Requirements - Facility did not ensure that CCL was notified about incidents after falls occurred on 2019 and 2020 including resident with Prohibited Condition (Stage III) wound. LPA reviewed incident report logs that confirmed that facility has been reporting incidents to CCL within regulations.
CCR 87465(g) - Incidental Medical and Dental Care - Facility failed to seek timely medical attention. LPA reviewed incident report logs received within 7 days as indicated per regulation.

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: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

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: 06/23/2023

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Continued from LIC809C...
HSC 1569.269 (a)(5) Enumerated Rights - Facility did not ensure that resident was accorded safe, healthful and comfortable accommodations which resulted in resident’s death as a result of a serious fall at the facility. LPA/Lead Staff observed residents who appeared to be safe, healthful and comfort.

CCR 87466 Observation of the Resident - Facility did not observe change of condition in resident after fall. LPA reviewed ten residents (R1, R2, R3, R4, R5, R6, R7, R8, R9 & R10) records and residents have been assessed for change of condition within the last 12 months per regulation.

CCR 87705 (c)(4) Facility didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs. LPA/Lead staff reviewed staff schedule for the month of June 2023 and facility has 6 direct care staff, 1 housekeeper, 1 kitchen for the morning shift; 5 direct care staff for the afternoon shift, 1 kitchen staff and 2 direct care staff for night shift to help with resident's needs. LPA reviewed staff training records and most of staff (S1 through S11) has received an average of 52 hours annual of training including care of persons with Dementia.

CCR 87506 Resident Records - Facility provided LPA with resident's care notes for review. Facility provided a care binder including memorandums from Administrator to staff, shower/teeth schedules, resident's weights, meals, incontinence care records to document daily resident's care notes. LPA/Lead staff observed daily care notes with initials documented for each resident.

Administrator will provide copies of the following by 7/7/2023: LIC 308 Designated of facility responsibility, LIC 500 Personnel Summary, LIC 610 Emergency Disaster Plan (if there are any changes), Copy of Administrator Certificate, Copy of Certificate of Liability Insurance

Deficiencies 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 with Lead Staff and appeal of rights provided.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 12:51 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	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, LPA/lead staff observed missing face cover plate in room# 7, bathroom in room #6 has an out of order sign, there are two drawers missing in shared bathroom for room# 4 and 5 which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agrees to fix maintenance issues and will provide receipts of service to CCL by POC due date to clear deficiency.

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in four out of six resident's bathrooms 123.8, 118.6, 121.6, 122.4, 108.1, and 127.9 degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 06/24/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agrees to turn hot water heater lower, and send a written statement that hot water temperature will be checked once/month, temperature log will be taken daily for one week, and send LIC9098 to CCL by POC due date to clear defiency.

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) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/23/2023 12:51 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	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/23/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87507(d)

Admisson Agreements

(d) The licensee shall retain in the resident's file the original signed and dated admission agreement and all subsequent signed and dated modifications. This does not apply to rate increases which have specific notification requirements as specified in Health and Safety Code section 1569.655. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA/Lead staff observation, interview and record review, the licensee did not comply with the section cited above in 29 out of 29 admission agreements were not updated after change of ownership indicating the changes including to the use of surveillance cameras in the common areas which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee/Administrator agrees to create an addendum indicating the change of ownership and use of surveillance cameras in the common areas. The addendum will be signed by residents or their responsible parties by POC due date to clear deficiency.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2023

LIC809 (FAS) - (06/04)

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