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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 04/07/2023
Date Signed: 04/10/2023 08:39:13 AM

Document Has Been Signed on 04/10/2023 08:39 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: DATE:
04/07/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH: Alex Varshavsky (Licensee)TIME COMPLETED:
02:30 PM
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An office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, and Licensee, Alex Varshavsky.

The purpose of this office meeting is to discuss non-compliance plan (NCC) from old facility Mirabel Lodge # 496800941 which will be rolled to new facility number 496804122 due to change of ownership. Licensee, Alex Varshavsky agreed to roll over the Non-compliance plan until expires on 7/28/2023, this was previously disussed during office meeting on 1/13/2023. The Regional Office will re-review progress made on Non-Compliance Plan of 2 years prior to expiration date. At the time of initial Non-Compliance Conference, CCL received policies and proof of corrections for non-compliance items and Licensee stated that they will keep in place for this facility.



- Timely Medical Attention: Facility failed to seek timely medical attention.

- Staffing: Facility didn't have adequate number of direct care staff to support each resident's physical, social, emotional, safety and health care needs.

- 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.

- Observation of the Resident: Facility did not observe change of condition in resident after fall.



- Resident Records: Facility wasn't able to provide CCLD with resident's care notes for review.

- Reporting Requirements: Facility did not ensure that CCL was notified about incidents after falls occurred on 2019 and 2020 including resident with Prohibited Condition (StageIII) wound.

There were no deficiencies cited at this time
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 04/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2023
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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