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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803416
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:29:21 PM


Document Has Been Signed on 05/19/2023 02:29 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 LODGE AT OAK MEADOWFACILITY NUMBER:
496803416
ADMINISTRATOR:BOTONES, ANNA KARINA PFACILITY TYPE:
740
ADDRESS:5161 OAK MEADOW DRIVETELEPHONE:
(707) 800-7364
CITY:SANTA ROSASTATE: CAZIP CODE:
95401
CAPACITY:6CENSUS: 5DATE:
05/19/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:33 PM
MET WITH:Cassie Guerrero (Lead Staff)TIME COMPLETED:
02:44 PM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a case management to follow up on the Pre licensing process initiated by a change of ownership. LPA was greeted by Cassie Guerrero (Lead Staff). Current Administrator Anna Botones was unable to come to the facility, but were available by phone and gave authorization for staff to sign the report.

During today's visit, LPA/lead staff toured the facility and observed the area under construction. LPA was informed by Administrator that the process to obtain a construction permit is still delayed by the City of Santa Rosa. Per Administrator, they are in constant communication with involved parties.

No deficiencies cited during today's inspection visit. An exit interview was conducted via phone with Administrator and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 05/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/19/2023
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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