Community Care Licensing

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
	VISIT DATE: 04/18/2024

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
	VISIT DATE: 04/18/2024

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type A

Section Cited

CCR

87202(a)

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in communal area and in one resident bedroom, there was a wheel chair stored in front of sliding glass door, obstructing the exit.which poses an immediate health, safety or personal rights risk to persons in care. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	LIcensee removed the wheelchairs immediately. Licensee will submit a written plan how they will ensure that nothing blocks the exits in the future to clear the citation by POC due date.

Type A

Section Cited

CCR

87303(a)

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 LPAs/Licensee observation and interviews the licensee did not comply with the section above two rusty shower chairs, holes in resident bedroom screen, two faucets broken in resident bedrooms, urine smell in resident room, ceiling fans observed covered with thick layer of dust, cement ramp not flush with cement walkway where residents walk, sticky floors in dining area, trash cans without lids/covers, lights not working, and broken electrical plate in resident room, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Licensee will submit a schedule plan of needed repairs that will be corrected in a timely manner by POC due date to clear the citation. LPA will return to ensure that repairs had been completed.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type A

Section Cited

CCR

87303(e)(2)

(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 LPAs/Licensee measured hot water in one resident bedroom tested was 131.6 F degrees which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Licensee will turn down the water heater and will implement a log to document water temperature is measured within regulation and will submit log sample to CCL by POC due date to clear the citation.

Type A

Section Cited

CCR

87303(i)(1)

(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observed auditory emergency signal system not working or lacking in 4 out of the 12 client bedrooms inspected, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Liecensee will develop a policy regarding how the facility will ensure all required emergency pendant/call bell alarm system are working properly and staff are following facility's policy/procedures/staffing to ensure a timely response in answering resident's emergency alarms to ensure that resident's needs, health & safety are being addressed appropriately and within regulations to CCL by POC due date to clear the citation.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type A

Section Cited

CCR

87465(c)(2)

(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 is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, records review and interview with Licensee, the licensee did not comply with the section cited above in spot check of medications were conducted and 4 out 5 residents (R1, R2, R3 & R4) medications were not given to residents according to their physician's order, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Licensee will submit written plan which addresses how facility will ensure compliance with 87465(c)(2) going forward. To be submitted to CCL by POC date in order to clear the deficiency.

Type A

Section Cited

CCR

87705(f)

(f) The following shall be stored inaccessible to residents with dementia: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observed storage cabinets containing potentially toxic chemicals unlocked in two communal restrooms. Aerosol hair products in drawer were observed in communal area and readily accessible to residents. Additionally, the laundry room door was observed unlocked and unattended with cleaning and laundry chemicals readily accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/19/2024
	Plan of Correction
1 2 3 4	Facility to send in written statement on how they will stay in compliance to CCL by POC due date to clear the citation.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type B

Section Cited

CCR

87219(a)

(a) Residents shall be encouraged to maintain and develop their fullest potential for independent living through participation in planned activities. The activities made available shall include: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee had a discussion regarding activities were not occurring during scheduled times. The licensee did not comply with the section cited above by not having any activities during LPA's visit which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	The licensee agrees to write a plan to designate a back up staff that could conduct activities as specified on the regulation for residents when designated staff is busy. Plan with designated staff responsible for activities will be submitted to CCL by POC due date to clear the deficiency.

Type B

Section Cited

CCR

87555(a)

(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPAs/Licensee observed expired canned goods, unpacked dry good not with expiration dates noted, and uncovered prepared foods in the walk-in refrigerator. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee will develop and implement a system in how they will ensure to properly store food to ensure quality of food and safety of residents. Licensee will submit written policy as proof of correction to CCL by POC due date.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type B

Section Cited

CCR

87467(a)(3)

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 4 out of five residents (R1, R2, R3 and R4) needs their care plan to be updated, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee to update and complete resident's Needs & Services Plan, with appropriate signatures of Licensee and Resident or resident's responsible party. Facility to submit LIC9098 form ensuring compliance with regulation to CCL by POC due date.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type B

Section Cited

CCR

87705(c)(3)

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 5 staff (S1, S2 & S3) do not have annual required training hours completed, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee to conduct staff required training. Licensee agrees to submit written self-certification LIC9098 by POC due date ensuring that staff have completed required training hours to clear the citation.

Type B

Section Cited

CCR

87705(j)

(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in auditory alarms on several resident bedroom sliding glass door exits were not activated, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Facility to send in written statement they understand regulation and how they will ensure they stay in compliance to CCL by POC due date to clear the citation.

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024

Document Has Been Signed on 04/18/2024 04:45 PM - It Cannot Be Edited

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/18/2024

Type B

Section Cited

CCR

87555(b)(6)

87555 General Food Service Requirements:(6) In facilities for sixteen (16) persons or more, menus shall be written at least one week in advance and copies of the menus as served shall be dated and kept on file This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not having dated menus on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/25/2024
	Plan of Correction
1 2 3 4	Licensee to ensure facility keeps track of meals that are served when they alter from what was planned. Licensee to submit self-certification form (LIC9098) notifying the Department that they are back in compliance with regulation by POC due date.

Section Cited

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

SUPERVISOR'S NAME: Bethany Moellers TELEPHONE: (707) 588-5040 LICENSING EVALUATOR NAME: Julie Florio TELEPHONE: (707) 588-5026 LICENSING EVALUATOR SIGNATURE: DATE: 04/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2024