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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 12/18/2025
Date Signed: 12/18/2025 06:06:20 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
10/06/2025 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20251006185042
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: DATE:
12/18/2025
UNANNOUNCEDTIME BEGAN:
04:08 PM
MET WITH:Alex Varshavsky, licenseeTIME COMPLETED:
06:20 PM
ALLEGATION(S):
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Staff did not seek medical attention to resident in a timely manner.
Staff did not notify resident's PCP of change in condition.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Coppo arrived unannounced to deliver findings on the above complaint allegations. LPA met with Administrative Assistant Jeralyn May. Licensee Alex Varshavsky arrived later.

Complaint alleges staff did not seek medical attention to resident in a timely manner. Complainant alleges that the facility waited to provide medical attention and care to address R1’s symptoms of sweating and difficulty breathing. Complainant alleges that R1 had been experiencing symptoms of hypoxia for two [2] days before facility called EMS on 8/25/25. It was reported to complainant that facility was “waiting R1’s symptoms out” to see if R1’s symptoms would subside before they would call EMS. However, the symptoms did not subside and the facility called EMS on 8/25/25. During investigation, LPA reviewed R1’s medical records. Medical records indicate R1 was hypoxic upon arrival to hospital. During investigation, LPA reviewed R1’s medical records. Medical records indicate R1 was hypoxic upon arrival at the hospital. During investigation, LPA reviewed chart notes for R1. Review of chart notes show that

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR 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.
LIC9099 (FAS) - (06/04)
Page: 1 of 4
Control Number 21-AS-20251006185042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 9099...

staff noted on 8/24/25 that “R1 continues to have a fever” and was given PRN Tylenol. Per regulation 87465(c)(3), a record of each PRN dose is to be maintained in the resident's record. The record shall include the date and time the PRN medication was taken, the dosage taken, and the resident's response. LPA requested the PRN MAR for R1 from the licensee, but licensee could not provide any PRN MAR for R1, instead licensee provided a MAR for prescription medications. However, MAR provided did not reflect the information required per regulation 87465(c )(3). Therefore, the facility could not show documentation that R1 was administered any medication on the day of 8/24/25 to address their fever and did not document R1’s outcome of receiving the medication, or if they ever actually received it.

Complaint alleges staff did not notify resident's PCP of change in condition. During investigation, facility provided LPA with proof of faxed notification to R1’s primary care physician (PCP) dated 8/31/25. However, staff (S2) advised LPA that R1’s PCP never responded to any of S2's faxed requests. S2 said they called and got clarification as to why all the requests were being ignored or not answered. S2 explained to LPA that they were advised by staff at PCP office that fax is not the best way to communicate and may result in communication not being acknowledged or received. During investigation, LPA reviewed written evidence showing that S2 acknowledged that communication via fax to R1's PCP was not the best way to communicate. S2 acknowledges that they were advised as such from the PCP on subsequent faxes they sent to R1’s PCP. However, S2 continued to send requests to the PCP via fax as evidenced by faxes sent on 6/2/25, 6/8/25, 8/24/25, and 8/25/25. So, although facility had previously been advised that fax is not the best way to communicate they continued to communicate only through fax.

Based on LPA’s interviews and record review, 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, are being cited on the attached 9099D. 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.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20251006185042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
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 1/5/25. 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 facility could not show that R1 received timely medical attention, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
12/31/2025
Section Cited
CCR
87465(d)
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87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the
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Facility to conduct an one hour duration of in- service training for all staff on medication management by plan of correction due date. Training logs submitted to show trainer, attendees, date, subject matter and duration.
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resident with self-administration provided all of the following requirements are met...This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility does not use PRN MARs for documenting the administration of PRN medication, which poses a potential 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20251006185042
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
12/31/2025
Section Cited
CCR
87211(a)(1)(A)
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87211 Reporting Requirements (a) Each licensee shall furnish... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the
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Faciliy to self-certify on a LIC9098 that they will maintain compiance with all reporting requierments as outlined in regualtion 87211
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resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that facility did not notify R1's PCP via a method of communication shown to be received which poses a potential 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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR 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
LIC9099 (FAS) - (06/04)
Page: 4 of 4