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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 07/09/2024
Date Signed: 07/09/2024 10:43:23 AM


Document Has Been Signed on 07/09/2024 10:43 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 LODGEFACILITY NUMBER:
496804122
ADMINISTRATOR:VARSHAVSKY, ALEXANDERFACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY:34CENSUS: 29DATE:
07/09/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:14 AM
MET WITH:Lisa DiBartolo (Administrative Assistant)TIME COMPLETED:
10:58 AM
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct this Case Management Visit to amend a report originally dated 05/23/2024. LPA met with Lisa DiBartolo (Administrative Assistant)

The document requires amending because secured perimeter was not reviewed by the Department on error when there was a change of ownership. The licensee have submitted pertinent documentation for the Department to review. The Fire Department is engaged and approval is pending. Currently, the facility is operating under fire clearance approved on 11/16/22 without secured perimeter waiver. Report was amended and signed today, 7/9/2024.

No citations were issued during this visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2024
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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