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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 03/13/2025
Date Signed: 03/13/2025 03:39:17 PM

Document Has Been Signed on 03/13/2025 03:39 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MIRABEL LODGEFACILITY NUMBER:
496804122
ADMINISTRATOR/
DIRECTOR:		VARSHAVSKY, ALEXANDERFACILITY TYPE:
740
ADDRESS:6950 MIRABEL ROADTELEPHONE:
(707) 887-1754
CITY:FORESTVILLESTATE: CAZIP CODE:
95436
CAPACITY: 34CENSUS: 33DATE:
03/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Lisa DiBartolo-Administrative AssistantTIME VISIT/
INSPECTION COMPLETED:
03:50 PM
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Licensing Program Analysts (LPAs) Contreras and Cuadra arrived unannounced to conduct the required 1-year annual inspection. LPAs met with Lisa DiBartolo, Administrative Assistant. The facility has residents receiving hospice services and residents with Dementia diagnoses. Annual fees are current. Required postings were observed. Contact information was reviewed.

Upon arrival, LPAs/staff noticed one gallon of detergent and 11 bottles of cleansers sitting on reception area accessible to residents. There were three staff around the reception area (technical advisory issued). LPAs/staff toured the facility inside and outside at approximate 9:30am: Facility has a centralized fire alarm system that is maintained by a vendor and inspected by the local fire department. Facility's last maintenance was conducted 12/19/24. Facility has a locked perimeter. Smoke detectors, sprinklers, carbon monoxide detectors were present throughout the facility. Fire panel was last inspected 12/19/2024. Last disaster drill was conducted on February 2025.

The facility is a one story building and has an approved fire clearance dated September 26, 2024 that allows for 34 ambulatory and 28 non-ambulatory residents and no bedridden resident. However, during records review two (R1 and R2) out nine residents have a bedridden status and are occupying room #1 (R1) and room #19 (R2), which are not cleared by the Fire Department as bedridden rooms. Licensee is operating outside the limitation of the license by accepting a bedridden resident in a non-ambulatory room. LPA/staff discussed the issue with R1 and R2 to provide the option to submit a request to the Fire Marshall to assess bedrooms to grant fire clearance. According to the Administrative Assistant, R1 and R2 are not bedridden and they have reached out during LPAs vitis to both physicians to obtain an updated physician's report (LIC602). During the visit, LPA spoke with R1 and R2 who expressed that they are not fully bedridden and they are in agreement to obtain an updated medical assessment. Fire Extinguishers were last serviced February 2024. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.
Continue on LIC809C...
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Ethel Contreras
LICENSING EVALUATOR SIGNATURE: DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/13/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122
VISIT DATE: 03/13/2025
NARRATIVE
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Continued from LIC809...
At approximate 9:45am LPAs pulled emergency alerts in resident's room (#5) and staff did not respond in a timely manner. According to Administrative Assistant, it appeared that the system was not on, so it did not alert staff to respond to call alerts. However, after the system was on, LPAs pulled the call alerts again and staff responded timely. At approximate 9:50am LPAs/staff observed auditory alarms in room #7 and #4 resident bedrooms sliding glass door exits were not activated (technical violation issued).

At approximate 10:00am LPAs/staff observed bathroom toilet in room 7 found cracked and staff placed out of order sign, sticky floor observed throughout facility and trash can with no lid was observed in bathroom room 20, Bathroom in room 12 observed with feces on floor in shared bathroom. Chairs in some resident's bedrooms were not available.

At approximate 10:05 am LPAs/staff observed unpacked dry goods with no expiration dates noted. Also, LPAs observed that residents were being served hot dogs, mashed potatoes and salad for lunch. LPAs held a conversation with staff regarding the importance to serve residents with nutritious food.

At approximate 10:10am LPAs/staff did not observed toilet paper and paper towels available to resident's in shared bathrooms.

Facility had sufficient perishable and non-perishable food. LPAs initiated file review at 11:00am. Nine residents and five staff files were reviewed. Residents have their care plan and medical assessments updated. Staff do have annual required training hours completed and at least one staff per shift have current CPR. During file review, LIC500 revealed that 2 out of 27 staff were cleared, but they were not associated to facility; LPA informed staff that the staff should never be working and providing care to residents prior to a criminal record clearance or exemption. Civil penalties are being assessed in the amount of $500 for allowing a person to work, reside or volunteer in the facility without a been associated to the facility. Administrator certificate for administrator Alex Varshavsky 7019479740 expires 7/15/26. At approximately 12:30pm a spot check of medications were conducted and 2 out 5 residents (R2 and R3) medications were not given to residents according to their physician's order.

Licensee to submit updates of the following documents by 3/27/25: Designation of Administrative Responsibility (LIC308), Personnel Report (LIC500), control of property and Liability Insurance.
Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview was conducted with Administrative assistant who was informed that the Department will be reviewing if further action is needed to address the overall compliance of the facility and a copy of this report was given.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Ethel Contreras
LICENSING EVALUATOR SIGNATURE:

DATE: 03/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/13/2025
LIC809 (FAS) - (06/04)
Page: 2 of 9
Document Has Been Signed on 03/13/2025 03:39 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/13/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87202(a)
Fire Clearance
(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal:

This requirement is not met as evidenced by:
Deficient Practice Statement
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4
Based on LPAs/staff observation, interview and record review, the licensee did not comply with the section cited above in all fire extinguishers were expired as February 2024 and two out of nine residents are bedridden which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Administrative Assistant immedicately contacted Fire Department to follow up on the reason why the fire extinguishers were not charged. Also, the facility faxed over physician's report for two residents (R1 and R2) to get updated ambulatory status corrected on LIC602s. The facility will submit self-certification as proof that both items were corrected to CCL by POC due date.
Type A
Section Cited
CCR
87303(i)(1)
Maintenance and Operation
(i) Facilities shall have signal systems which shall meet the following criteria: (1) All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in one out of three call alert staff did not repond timely to call monitors due to system was off which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Administrative Assistant turned on the alert system and staff was able to get alerts about residents needing help while in their room. The facility will submit a written plan about how they will ensure the system is maintained on to alert staff by POC due date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Ethel Contreras
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
Page: 3 of 9
Document Has Been Signed on 03/13/2025 03:39 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/13/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/staff observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 27 staff were cleared, but they were not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Administrative Assistant immediately associated staff to their roster through Guardian. THe facility will submit LIC9098 self-certification form certifying that they will monito their facility roster regularly to prevent staff not been associated to the facility timely.
Type A
Section Cited
CCR
87465(c)(2)
Incidental Medical and Dental Care Services
(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents were not given their medications as prescribed which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 03/14/2025
Plan of Correction
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Administrative Assistant agrees to review medication of all residents to ensure that medication are given to residents as prescribed by their doctor and will submit a self-certification form acknowledging the review of medications to CCL by POC due date,
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:Kimberley Mota
LICENSING EVALUATOR NAME:Ethel Contreras
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 03/13/2025 03:39 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/13/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in bathroom toilet in room 7 found cracked and staff placed out of order sign, sticky floor observed throughout facility and trash can with no lid was observed in bathroom room 20, Bathroom in room 12 observed with feces on floor in shared bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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Administrative Assistant agreed to submit pictures as proof of repairs/clean areas of concern to CCL by POC due date.
Type B
Section Cited
CCR
87307(a)(3)(D)
Personal Accommodations and Services
(D) Hygiene items of general use such as soap and toilet paper.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in No toilet paper or paper towels found in residents room which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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The facility will submit a written plan regarding how they will resolve this recurrent issue about toilet paper and paper towels to CCL by POC due date.
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:Kimberley Mota
LICENSING EVALUATOR NAME:Ethel Contreras
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 03/13/2025 03:39 PM - It Cannot Be Edited


Created By: Ethel Contreras On 03/13/2025 at 02:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/13/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87555(a)
General Food Service Requirements
(a) The total daily diet shall be of the quality and in the quantity necessary to meet the needs of the residents an shall meet the Recommended Dietary Allowances of the Food and Nutrition Board of the National Research Council. All food shall be selected, stored, prepared and served in a safe and healthful manner.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA's/staff observation and interview, the licensee did not comply with the section cited above by having unpacked dry goods with no expiration dates noted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 03/27/2025
Plan of Correction
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ADministrativa Assistant contacted their food supply vendor to inquire about the reasons of the missing information on food packaged delivered. The facility agreed to write down expiration dates on food packages and will submit pictures of dates written on goods that did not have expiration dates on them to CCL by POC due date.
Section Cited
Deficient Practice Statement
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2
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POC Due Date:
Plan of Correction
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2
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4
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:Kimberley Mota
LICENSING EVALUATOR NAME:Ethel Contreras
LICENSING EVALUATOR SIGNATURE:
DATE: 03/13/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/13/2025


LIC809 (FAS) - (06/04)
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