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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
496803871
Report Date:
06/09/2023
Date Signed:
06/09/2023 09:29:53 AM
Document Has Been Signed on
06/09/2023 09:29 AM
- 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 CARNATION
FACILITY NUMBER:
496803871
ADMINISTRATOR:
SERKISSIAN, ALAIN
FACILITY TYPE:
740
ADDRESS:
6992 MIRABEL RD
TELEPHONE:
(707) 820-1234
CITY:
FORESTVILLE
STATE:
CA
ZIP CODE:
95436
CAPACITY:
6
CENSUS:
0
DATE:
06/09/2023
TYPE OF VISIT:
Case Management - Licensee Initiated
UNANNOUNCED
TIME BEGAN:
08:37 AM
MET WITH:
Alain Serkissian (Licensee)
TIME COMPLETED:
09:25 AM
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Licensing Program Analyst (LPA) Cuadra arrived at the home for the purpose of conducting a closure inspection pursuant to voluntary closure of this licensed Residential Care Facility for the Elderly. LPA arrived and was allowed in by the Licensee Alain Serkissian. LPA/Licensee toured the facility and licensee told LPA that they want to retire.
LPA inspected all rooms and the exterior of the building today and found no evidence that would suggest that any clients are residing on the premises. All clothing and personal items belonging to clients have also been removed.
The Licensee initiated this facility closure with plans for retirement and did not submitted a closure plan. On 5/25/2023 LPA received a phone call from Licensee notifying CCL about their plan to close the facility. Licensee submitted to CCL an eviction letter that was given to residents and their responsible parties regarding the facility's plan to close dated 5/22/23. Closure of this facility has been finalized. Facility was closed effective 6/9/23. Licensee turned over copy of License during today's inspection.
No deficiencies cited during today's visit.
SUPERVISOR'S NAME:
Bethany Moellers
TELEPHONE:
(707) 588-5040
LICENSING EVALUATOR NAME:
Marisol Cuadra
TELEPHONE:
(707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE:
06/09/2023
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
06/09/2023
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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