496804122-4-17-2026-21-AS-CCOO-DT92B4-20260417171432

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 04/17/2026
Date Signed: 04/17/2026 05:14:41 PM

Document Has Been Signed on 04/17/2026 05:14 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496804122
ADMINISTRATOR/ DIRECTOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY: 34		CENSUS: 31	DATE:	04/17/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:29 AM
MET WITH:	Alex Varshavsky, licensee		TIME VISIT/ INSPECTION COMPLETED:	05:29 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) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by Lisa DiBartolo, Administrator Assistant (AA). Licensee Alex Varshavsky was also present. Licensee Administrator certificate 7019479740 expires 7/15/26. Facility currently has thirty one (31) residents in care five (5) of which are currently on hospice. LPA went over staff associated to facility with AA. Staff (S1) was found to have fingerprint clearance but not associated to the facility (deficiency cited, see 809D). At approximately 9:30am LPA and licensee toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food in the kitchen was found to be stored in a safe manner with open items covered and labeled with opened dates present. Facility has a food storage room. Food storage room there are pesticides and toxins present (deficiency cited, see 809D). All other cleaning products and laundry soaps are located in the dedicated cleaning closet or laundry room. All bedrooms were equipped with lighting. Rooms #2, #3, #15, and #17 need a chair and #11 and #12 need another chair as they are a shared room. Rooms #14, #4, #6, #9, needs a chest of drawers and #12 needs another a chest of drawers as it is a shared room (deficiency cited, see 809D). Shower in room #15 and room #4 need a grab bar (deficiency cited, see 809D). All other resident bathrooms had required bath mats and grab bars. Facility had common towels present in shared rooms and all but two (2) other resident rooms did not have paper towels present. Per licensee, facility does not keep Continued on 809C...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
	VISIT DATE: 04/17/2026

NARRATIVE

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Continued from 809...
paper towels in resident rooms purposely, licensee claims residents flush them down the toilets (deficiency cited, see 809D). Room #!1 has a broken vanity cabinet door and room #2 has broken blinds. Internal courtyard has deck planks that do not meet, leave holes present such that one can see through to the ground, per licensee these planks were just repaired. However, wood panel just outside of room #14 leading to internal courtyard is splintered, bows and bends with pressure and has black substance present. Facility food storage room has a floor that bows and bends when pressure is applied (deficiency cited, see 809D). Triple antibiotic ointment with active ingredients of Bacitracin Zinc 400 units, Neomycin Sulfate 3.5mg, Polymyxin B Sulfate 5000 units was found by LPA and licensee in room #20 (deficiency cited, see 809D).

Extra hygiene products and linens were available. Water temperature in sinks measured at 118.2 degrees F in the kitchen, 110.6 degrees F in room #20, 106.9 degrees F in the common bath/shower room, 108.2 degrees F in room #11, and 106.2 degrees F in room # 15 all of which are within the allowable range of 105 to 120 degrees F. Facility has another bathroom used by staff only.

Fire extinguishers were last inspected 03/18/26. Sprinklers were tested and serviced by vendor on 3/18/26 all systems pass. Smoke detectors located throughout the facility are serviced by vendor, all systems passed, last service date was 6/2/25. Carbon monoxide detector present in facility. LPA and licensee tested detector and found it functional and operational. Facility’s last quarterly disaster drill was conducted on 01/20/26. Facility has a backup generator for use during a power outage.

At approximately 11:00am LPA, licensee, and Administrator Assistant conducted a spot check of medication and medication records. Medication is centrally stored in two (2) locked medication carts. The following errors were found for resident (R1): prescribed Mentol-Zinc Oxide, hydrocortisone 1% cream, and Miconazole 2% were listed on the current physician's orders but not present on the Centrally Stored Medication log (CSML) (deficiency cited, see 809D). Morphine 20mg was on the CSML but the wrong instructions were listed. Instructions on physician's orders were: take by mouth every hour as needed for pain or shortness of breath, but CSML listed for it be administered "2X per day" (deficiency cited, see 809D). Senna 8.6 mg bubble

Continued on 809C(2)...

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE	FACILITY NUMBER: 496804122
	VISIT DATE: 04/17/2026

NARRATIVE

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Continued from 809C...

pack was stared 4/2/26 to be administered on Mondays and Thursdays 1 tab 2 times per day. Total tabs in bubble pack on 4/2/26 was 31 and today 22 pills remain, so facility is under by 1 tab (deficiency cited, see 809D).

At approximately 2:00pm LPA conducted a review of eight (8) out of thirty-one (31) resident files. R1 had a medical assessment dated 12/2024. Per AA, facility has been requesting an updated medical assessment since 3/2026. LPA reviewed documentation of requests. Request dated 4/8/26. LPA advised that request for an updated medical assessment should begin no later than the same month in which the update is due and if the facility makes an attempt to get an update be sure document the request, such a a fax transmission or copy of email. All other documentation present. No deficiencies cited.

LPA and Licensee discussed Infection Control Plan. LPA and Licensee discussed Emergency Disaster Plan. AA confirmed no updates needed.

LPA will return at a later date to complete annual inspection and issue citations for those items identified in today's report as well as any other deficiencies identified when LPA returns to complete annual inspection.

Exit interview conducted with licensee and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/17/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026

LIC809 (FAS) - (06/04)

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