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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496800941
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:34:26 PM


Document Has Been Signed on 01/13/2023 02:34 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: 0DATE:
01/13/2023
TYPE OF VISIT:OfficeUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alex Varshavsky (Administrator)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 Regional Manager Carla Nuti-Martinez, Licensing Program Manager Bethany Moellers, Licensing Program Analyst Marisol Cuadra and acting Administrator/Applicant Alex Varshavsky.

The purpose of the office meeting was to discuss the non-compliance plan initiated on 7/28/2021. There is a pending approval for a change of ownership for Mirabel Lodge #496800941 involving acting Administrator/Applicant who was informed and confirmed understanding that the current non-compliance plan will be transferred to the new license issued which will expire on 7/28/2023 only if the facility maintains substantial compliance until this date.

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: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023
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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