496804122-7-9-2024-21-AS-BMOS-D5QNE8-20240529102331

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 05/23/2024
Date Signed: 07/09/2024 10:37:00 AM

Unfounded

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
05/02/2024 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240502172136

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496804122
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE:	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 28	DATE:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	12:18 PM
MET WITH:	Lisa DiBartolo (Administrative Assistant)		TIME COMPLETED:	02:39 PM

ALLEGATION(S):

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-Facility does not maintain a proper fire clearance.

INVESTIGATION FINDINGS:

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***Amending LIC9099 and LIC9099C. Upon change of ownership on 4/3/23. The secured perimeter was not reviewed by the Department on error. 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 clarance approved on 11/16/22 without secured perimeter waiver. Complaint disposition will be changed to Unfounded due to facility secured perimeter waiver was not approved.
Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrative Assistant, Lisa DiBartolo .
The Department received an allegation of facility does not maintain a proper fire clearance. Per Reporting Party, on 05/02/2024 an unsafe situation was observed at the front gate was locked and impassable. Administrator’s assistant was sitting at the front desk and failed to inform visitors that the gate was not working. The reporting party attempted to exit from a side gate, which is typically unlocked, and found that gate locked as well. At that point, they went inside to find someone with a key to let them out. On the same date, LPA was conducting a visit for an unrelated situation, Licensee was standing outside of the facility, notified LPA about the issue with the gate code not opening the door every time and escorted LPA through the side gate which was locked at the time of visit. Licensee showed LPA a sign placed on the front door indicating that front door was not working and referring visitors to use side door.
Continues on LIC9099C...

Unfounded

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: 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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240502172136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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	FACILITY NUMBER: 496804122
	VISIT DATE: 05/23/2024

NARRATIVE

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Continued from LIC9099...

Based on records review, on 5/3/24 Licensee provided LPA with written communication with the vendor that came to fix the issue on 5/2/24 indicating the following: “This email confirms our appointment for next Tuesday, 5/7/24 at 9-10 AM. As requested, the gate maglock replacement was ordered after our visit in the afternoon of 5/2/24. The gate maglock, exterior button, and inner keypad were all functioning during this visit. We will replace the maglock as agreed upon, ruling out a faulty unit since the maglock is EOL. We will also be installing a new concealed closer inside the gate-welded housing. On 5/7/24, LPA conducted a subsequent visit to the facility. Upon LPA’s arrival, the Licensee and two workers were standing outside replacing the parts at the front door. At approximate 1:13pm, Licensee notified LPA that the door was repaired and was working according to regulation. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6, Chapter 8), is cited on the attached LIC 9099D. Appeal Rights Given. **Immediate Civil Penalty assessed in the amount of $500.

***Amending LIC9099 and LIC9099C. Upon change of ownership on 4/3/23. The secured perimeter was not reviewed by the Department on error. 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 clarance approved on 11/16/22 without secured perimeter waiver. Complaint disposition will be changed to Unfounded due to facility secured perimeter waiver was not approved.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20240502172136

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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	FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/23/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/24/2024 Section Cited CCR 87203	1 2 3 4 5 6 7	Type A 87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement has not been met as evidence by:	1 2 3 4 5 6 7	Facility will ensure all exits are always free from obstructions. Licensee will send in written statement to CCL that they understand and will be complying to regulation 87203. POC due date. **Immediate Civil Penalty assessed in the amount of $500.
	8 9 10 11 12 13 14	Based on records obtained and interviews conducted with licensee, the licensee did not comply by not ensuring the ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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