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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 10/18/2022
Date Signed: 10/18/2022 03:06:42 PM


Document Has Been Signed on 10/18/2022 03:06 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 LODGEFACILITY NUMBER:
496800941
ADMINISTRATOR:VARSHAVSKY, ALEXANDERFACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: DATE:
10/18/2022
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Alain Serkissian (Licensee)TIME COMPLETED:
02:15 PM
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An office meeting was conducted today in the Santa Rosa Regional Office via Microsoft Teams due to Covid19 precautions. Present in the meeting were Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra, Administrator Alex Varshavsky and Licensee Alain Serkissian.

The purpose of the office meeting was to discuss the change of ownership for Mirabel Lodge #496800941, to date a new application has not been submitted to the Department. License acknowledges that he is responsible for the operation until new application is approved and issued. Licensee following verbal conversation on 6/3/2022 provided a lease agreement to ensure control of property. Administrator confirms understanding that the current license is not transferable and an application is required to be submitted to the Department for change of ownership.

Licensee was advised about civil penalties for Substantiated findings for complaint #21-AS-20201207072042 that are still under review by the Department.
No deficiencies cited during today's office meeting
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2022
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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