496804122-1-9-2024-21-AS-VBEI-CZCTRF-20240110135724

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 01/09/2024
Date Signed: 01/09/2024 03:02:14 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
12/01/2023 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20231201111149

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: 32	DATE:	01/09/2024
		UNANNOUNCED	TIME BEGAN:	01:34 PM
MET WITH:	Ana Martinez (Med-Technician)		TIME COMPLETED:	03:17 PM

ALLEGATION(S):

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Staff did not ensure that resident received their medication as prescribed while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Ana Martinez (Med-Technician). Licensee, Alex Varshavsky was available by phone and gave authorization to staff to sign the report.

The Department received an allegation of staff did not ensure that a resident received their medication as prescribed while in care. Per Reporting Party, R1 had been exhibiting behavior issues as yelling, excessive crying, and depression, not wanting to be touched, wandering at night, getting aggressive with staff, when they became aware that the facility has not been ensuring that resident (R1) was receiving their medication (Zoloft-Sertraline) as prescribed by their physician for the last three months, which led them to think that exhibited behavior was the result of missing the medication dosage. On 12/4/23, LPA conducted a 10-day visit to investigate the complaint allegation.

Continues on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231201111149

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: 01/09/2024

NARRATIVE

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Continued on LIC9099...

Based on records review, the facility provided during LPA's visit an incident report dated 12/5/23 indicating the following: “R1’s medication name Sertraline did not get order and R1 was not taking it.
Once, we realized that there was an error in our ordering system, the error was corrected, the medication was ordered, and R1 is taking their medication as prescribed”. The facility also provided LPA with the Centrally Stored Medication Log (CSMR) for involved resident, which revealed that Sertraline 100mg/2 times per day (200 tabs supply) date filled was 3/3/23 and the next order was filled until 11/10/23, confirming that R1 was not assisted with the medication since June 2023. Based on interviews conducted with facility staff and outside parties. It was also discovered that the way that the facility is managing resident’s medications was a system where each resident’s medications were placed in their own "little box", and staff were supposed to look at the medication bottle to determine when a refill was due, but in R1's situation they never looked at the refill date so R1 was suddenly no longer getting their Zoloft. This medication is a very dangerous antidepressant due to people are supposed to gradually wean off them and not to be discontinued abruptly as occurred in this case. During records review of facility medication management protocol, it was revealed that the facility has a designated medication technician (S1) responsible for coordinating medication orders and ensuring that they are delivered in a timely manner. However, the designated med-tech is no longer working at the facility. Also, the facility have not contacted a pharmacy to review their medication management at least twice per year as required by regulation. 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.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20231201111149

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: 01/09/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 01/10/2024 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	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. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Licensee agrees to conduct a medication audit, retrain staff on medication management from an outside vendor & will write a plan to ensure resident medications are logged into the Centrally Stored Medication Records daily. Licensee to submit the updated plan to CCL by POC due date to clear the citation.
	8 9 10 11 12 13 14	Based on interviews with staff and records review Licensee did not ensure proper management of medication by medication technician staff (S1) who are responsible for medication management of all residents in care which poses an immediate risk to the health & safety of residents in care.	8 9 10 11 12 13 14
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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 Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC9099 (FAS) - (06/04)

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