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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 04/17/2026
Date Signed: 04/17/2026 05:13:02 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
12/24/2025 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20251224093221
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:
04/17/2026
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrative Assistant, Lisa DiBartoloTIME COMPLETED:
05:27 PM
ALLEGATION(S):
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Facility not meeting resident care needs
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 Lisa DiBartolo and Licensee Alex Varshavsky.

Licensing Program Analyst (LPA), Coppo conducted an investigation into the allegation of “facility not meeting residents care needs." LPA Coppo and LPA Contrerras conducted interviews with nine (9) facility staff, the licensee/administrator, four (4) outside parties who had knowledge of resident's (listed as R1) care needs, reviewed facility records, ER discharge notes, and physician notes as well as other documentation related to R1. The following information was obtained.

Complaint alleges that resident, R1 had a scheduled phone appointment on 12/22/2025, which was missed due to facility not answering the phone. A voicemail was left but not returned. The following day

Continued on 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/16/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2026
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 3
Control Number 21-AS-20251224093221
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: 04/17/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/24/2026
Section Cited
CCR
87465(a)(1)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents.
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Facility to arrange for personal rights training and what medical professionals are best suited to assess residents needs with local ombudsman by plan of correction due date. Training to take place no later than 5/8/26, licensee to attaned training as well as all care
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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 staff did not provide the care that was required for R1, which poses an immediate health, safety or personal rights risk to persons in care.
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staff and Administrative Assistant. Additonally, facility to submit to CCL a written defined policy outlining the facility protocols for those incidents where residents need medical attention as noted by after visit summaries, Emergency Medical Services personnel or reports, doctors or any medical professional reports or suggestions, and staff observation. Written policy to include chain of command for reporting and identification of staff repsonsible for each action idenified in chain of command. Written policy due by plan of correction due date. Lastly, facility to submit proof of staff training on Observation of a Resident, regulation 87466 and the chain of command policy. Training to be completed no later than 5/1/26.
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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: 04/17/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 21-AS-20251224093221
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: 04/17/2026
NARRATIVE
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Continued from 9099...

resident was sent to the hospital for being “warm to touch.” Complainant expressed concern that R1 is non-verbal with dementia, is unable to verbalize pain and was sent to the emergency room alone. Per file review, a record of R1’s temperature was not documented.

Review of the After Visit Summary indicated that resident was diagnosed with a Urinary Tract Infection and Dental Caries with after care instructions indicating that they were to follow up with their medical doctor in “1 day (around 12/24/2025)” and were to “see a dentist as soon as possible for evaluation for tooth extraction.” Facility was unable to provide documentation showing that there was a follow-up with their doctor within one day, as instructed in that after visit summary, or that an appointment was sought by the facility for a follow-up with a dentist. A follow up visit was conducted on 1/6/2026 with R1’s Nurse Practitioner.

Per Nurse Practitioner’s order R1 has “gingivitis (gum inflammation) and also periodontitis - inflammation around the root of the molar, which is "cracked” and defined that treatment will be an extraction or root canal under anesthesia. The doctor’s order went on to say that as an intermediate step, have the visiting dental hygienist conduct a thorough cleaning of R1’s teeth and gumline. Order instructed facility that if R1 still has tenderness, inflammation, poor appetite, mouth pain, or behavior changes 1-2 weeks after the cleaning, R1 will likely require further evaluation and treatment with extraction or root canal. Finally, the facility was instructed to “provide mouth hygiene on a daily basis; use Orajel on toothbrush first to numb the gum line, then use Sensodyne toothpaste paying special attention to the upper right molars.”

Interviews with five (5) staff indicated they assist R1 with teeth brushing but three of five were unaware of any special instructions with the remaining two not having a response to the question. Individual staff noted that R1 bites their toothbrush when staff are trying to brush their teeth and swallows the water with two staff indicating it is difficult for the resident to open their mouth. Based on review of R1’s file, the care plan was not updated following the emergency room visit or the nurse practitioner’s order to reflect changes in R1’s care needs.

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.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 04/17/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/17/2026
LIC9099 (FAS) - (06/04)
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