<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 03/28/2023
Date Signed: 03/28/2023 11:05:11 AM


Document Has Been Signed on 03/28/2023 11:05 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: 31DATE:
03/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Alex Varshavsky (Applicant/Administrator)TIME COMPLETED:
11:15 AM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst Cuadra arrived announced to conduct a Pre-licensing Continuation Facility Inspection and met with Applicant/Administrator Alex Varshavsky. A pre-licensing inspection was completed on 03/13/2023.

During today’s visit LPA observed the following items:

· Exits were observed free from obstructions, Rooms# 2,4 and 6 were unobstructed as stated per regulation.
· Installed auditory alarms were tested and found operational.

Applicant has satisfied all requirements in accordance with Title 22, California Code of Regulation. However, On 1/13/23 current Applicant/Administrator was informed and confirmed understanding that the current non-compliance plan for facility Mirabel Lodge #496800941 will be transferred to the new license issued which will expire on 7/28/2023 only if the facility maintains substantial compliance until this date. LPA will notify Application Unit Pre-licensing inspection is complete to proceed with the process of license. Pre-Licensing deficiencies have been resolved. Pre-Licensing is now complete.

No deficiencies cited at today’s inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 03/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1