496800941-10-20-2022-21-AS-BMOS-CKKQ8N-20221026115702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496800941
Report Date: 10/20/2022
Date Signed: 10/20/2022 09:01:09 AM

Unsubstantiated

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
10/05/2022 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20221005125355

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496800941
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 33	DATE:	10/20/2022
		UNANNOUNCED	TIME BEGAN:	08:34 AM
MET WITH:	Diandra Chadwick (staff)		TIME COMPLETED:	09:16 AM

ALLEGATION(S):

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Unlawful eviction.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with staff Diandra Chadwick.

Complaint alleges unlawful eviction. Based on a review of records and confidential interviews, Resident (R1) was provided with a lawful eviction notice on 09/16/2022 due to non-payment which CCL received a copy. On 10/4/22 R1 was sent to the Emergency Room due to health issues. R1 was medically cleared for discharge the same day. However, Administrator denied resident’s admission due to standing eviction notice for non-payment. On 10/5/22 after payment arrangements were made R1 returned to the facility. On 10/18/2022 LPA had a conversation with Licensee and Administrator regarding eviction procedures and both confirmed understanding of the regulation. A finding that the complaint allegation unlawful eviction is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.
No deficiencies cited during today's visit. A copy of the report was provided.

Unsubstantiated

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: 10/20/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022

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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