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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 12/18/2025
Date Signed: 12/18/2025 06:02:49 PM

Document Has Been Signed on 12/18/2025 06:02 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: DATE:
12/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Alex Varshavsky, licenseeTIME VISIT/
INSPECTION COMPLETED:
06:17 PM
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Licensing Program Analyst (LPA) Coppo arrived unannounced to conduct this Case Management Visit to follow up on incident reports and a death reported received by the facility. LPA met with Administrative assistant Jeralyn May. Licensee Alex Varshavsky arrived later.

On 10/19/25 facility submitted an Incident Report for resident R2 indicating that on 10/17/25 R2 was found in their room shaking. Emergency Medical Services (EMS) were called and R2 was taken to the hospital. R2 was seen for a new seizure like activity, dehydration, and a urinary tract infection (UTI). A follow-up appointment was scheduled for 12/2/25. On 10/30/25 the facility submitted an Incident Report for R2 indicating that on 10/29/25 R2 was observed to have a dark colored urine, presenting as weaker than baseline, and seemed more confused than baseline. The facility called EMS and R2 was taken to the hospital. On 11/10/25 facility submitted a Death Report for R2 stating the date of death as 11/2/25 with the immediate cause listed as cardiopulmonary arrest. Conditions prior to or contributing to death were listed as septic shock due to urosepsis/UTI with underlying cause: acute metabolic encephalopathy.

On 12/8/25 facility provided R2's Death Certificate to CCL for review. Review of Death Certificate shows causes of death and underlying causes to be the same as facility listed on death report submitted: immediate cause listed as cardiopulmonary arrest. Conditions prior to or contributing to death were listed as septic shock due to urosepsis/UTI with underlying cause: acute metabolic encephalopathy.

During case management visit, LPA reviewed chart notes and conducted interviews. Per R2's chart notes on

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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: 12/18/2025
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Continued form 809...

10/23/25 and 10/24/25 R2 experienced falls. No chart notes found in relation to symptoms R2 was experiencing on the days before or after R2's visit to the hospital on 10/17/25. One chart note mentions that R2 went to the hospital because they were "not looking well" and that their eyes would roll back and looked like R2 was having a seizure. Notes indicate that the hospital called and said R2 had a UTI. However, there are no initials for chart note entry and no date listed. LPA also reviewed R2's discharge papers from their hospital visit on 10/17/25. Discharge papers indicate diagnosis of UTI and reason for the visit listed as seizure. LPA review of R2's physician's report dated 7/24/25 shows R2 has a history of UTIs. Review of facility communication with R2's doctor shows they notified the doctor 3 separate times on 10/19/25 indicating that R2 was on antibiotics, having trouble with bowel movements, and not able to hold their medications in their hand without dropping them and having difficulty swallowing them. An order for crushed medications and Miralax were requested.

During case management visit LPA conducted interviews. Interviews did not provide any clarifying information. It is not clear when R2 began exhibiting a change of condition. LPA spoke to licensee about the importance of clear, accurate, and thorough documentation and charting notes.

On 11/25/25 facility submitted an Incident Report for resident R3 indicating that for several weeks R3's toe had been progressively darkening in color. Facility notified R3's primary care physician (PCP), R3 was prescribed antibiotics and was scheduled for a podiatry appointment on 11/25/25. On 11/20/25 facility noticed that R3's toe seemed to be getting worse. Facility reports to have sent an updated request to her PCP but reports they did not receive a response. On 11/23/25 the discoloration of R3's toe had further deteriorated. Due to R3's decline facility requested a professional non-emergency evaluation. After EMS performed an evaluation R3 was transported to the hospital for assessment. R3 is currently back at the facility.

During case management visit, LPA reviewed R3's chart notes and conducted interviews. Interviews yielded conflicting dates of care and notification to R3's doctor. However, chart note shows that on 9/29/25 R3 was

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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: 12/18/2025
NARRATIVE
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Continued from 809C...

experiencing a lot of pain, their leg was swollen and purple, and they could not stand on their leg at all the entire day. One other chart note indicated that R3 complained of pain in their left leg but the date of the chart note is illegible. Interview conducted reports that R3 was exhibiting the same swollen purple leg for at least one week.

During case management visit, LPA reviewed R3's After Visit summary which indicated that R3 was seen for cellulitis and was prescribed antibiotics for 10 days and diagnosed with a primary diagnosis of a pressure ulcer of the left toe deemed unstageable, the ulcer was covered by slough and/or eschar and an ulcer of the right toe with unspecified depth; cellulitis. R3 is now on hospice.

During case management visit, LPA reviewed facility communication with R3's doctor. On 11/12/25 facility faxed R3's doctor informing them that R3's toe looks about the same and that they have bright red cellulitis with watery drainage and the toe nail looks as if it is going to fall off. Additionally, the facility advised the doctor they had been covering it with a small amount of antibiotic ointment and a non-stick bandage. On 11/13/25 the doctor responded advising to continue with care facility had previously described and instructed facility to make a podiatry appointment for R3. An appointment was scheduled for 11/25/25. On 11/20/25 facility faxed doctor indicating R3 had completed the round of antibiotics prescribed on 11/6/25 but was not improving; in fact, they wrote, the condition is worsening. Per licensee, the doctor did not respond. On 11/23/25 at 5:50pm licensee faxed R3's doctor urgently requesting advise on the next steps to be taken for R3 since R3 was still showing no signs of improvement and was worried about the possibility of tissue necrosis or some other serious underlying condition.

A deficiency of regulation 87411(a) is being cited today as facility did not seek timely medical care as evidenced by having a purple and swollen leg since at least 9/29/25 but was not seen by a doctor until 11/6/25 (deficiency cited, see 809D).

Additionally, During a complaint investigation, Licensing Program Analysts (LPAs) Cuadra and Coppo attempted to conduct interviews with staff to inquire about the timely medical care of a resident. As a result,

Continued on 809C(3)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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: 12/18/2025
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on 11/13/25, licensee Alex Varshavsky sent an email to CCL advising that he has instructed his staff not to discuss any resident information with external callers, to refer all inquires immediately to the Administrator or facility office, and to report any unusual or suspicious calls. On the same day, Licensing Program Manager (LPM) Bethany Moellers responded to the licensee and advised that “the department has jurisdiction to contact the staff directly during complaint investigations and/or other matters which does not require being filtered through facility administration. This [instruction] appears to be placing a divide between your staff and the department.” The licensee then responded to LPM that he has now revised his instruction to his staff to be, “we want to remind you to be cautious about calls from anyone asking for information about our residents. If you receive such a call, please ask the caller to contact the facility directly with any questions, and then politely end the conversation. We do not share your phone numbers or allow anyone to call you about residents. The licensee went on to further instruct his staff: We want to remind everyone to be cautious when receiving unexpected calls, especially those asking about our residents or facility operations. Licensing Program Analysts (LPAs) and the Department do at times contact staff directly as part of official investigations. However, because fraudulent calls are increasingly common, it is important that any unexpected caller be verified before you share any information or continue the conversation. If someone calls and identifies themselves as being from the Department, it is completely appropriate - and encouraged - to request verification. You may politely ask the caller to send a confirmation email to you or to the facility office before proceeding.”

Subsequently, on 11/19/25, LPA Coppo attempted to interview staff. During investigation, it was reported to LPA that staff S1 had first-hand knowledge of R1’s condition of health before facility called EMS; however, S1 reported to LPA “that people from the state don't usually call employees asking about residents. S1 explained that this recently was talked about from the owners and they told everyone to have CCL contact the owners with any questions we had.” So, LPA was not able to conduct interview with staff.

During this visit, LPA discussed the importance of confidential interviews as part of an investigation and while facility staff should not provide protected information regarding residents to individuals, they are able to provide information to CCL staff. LPA provided regulation 87755 Inspection Authority of the Licensing Agency

Continued on 809C(4)....

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
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: 12/18/2025
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which states in part, “The licensee shall ensure that provisions are made for private interviews with any resident or any staff member; and for the examination of all records relating to the operation of the facility” and Health and Safety Code 1569.37 Whistle blowers; retaliation.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. Appeal rights given and discussed with licensee. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

Exit interview conducted with licensee and a copy of this report was given.

NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 06:02 PM - It Cannot Be Edited


Created By: Christi Coppo On 12/18/2025 at 04:01 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: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
12/19/2025
Section Cited
CCR
87411(a)

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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement not met
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Facility to conduct in-service training on personal rights and providing timely medical care. Facility to submit plan to conduct training by plan of correction due date. Training to be completed no later than 1/5/26. Training logs submitted to show trainer, attendees, date, subject matter and duration.
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by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that R3 did not receive timely medical care, which poses an immediate health, safety or personal rights risk to persons in care.
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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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


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