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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 05/11/2026
Date Signed: 05/11/2026 03:50:35 PM

Unsubstantiated


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
02/12/2026 and conducted by Evaluator Christi Coppo
COMPLAINT CONTROL NUMBER: 21-AS-20260212082027
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: 32DATE:
05/11/2026
UNANNOUNCEDTIME BEGAN:
12:54 PM
MET WITH:Licensee Alex VarshavskyTIME COMPLETED:
04:05 PM
ALLEGATION(S):
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Facility is in disrepair
Call button is in disrepair resulting in resident's needs not being met
Personal rights
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.

Complaint alleges facility is in disrepair. Complainant states that there are no towel racks on which residents can hang their towels. During investigation, LPA observed hand towel racks approximately 6 inches long present in bathrooms of residents. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complaint alleges personal rights. Complainant states that staff do not provide resident (R1) with certain food items such as butter or salt and pepper. Review of R1’s medical assessment did not indicate a special diet. During investigation, LPA observed a butter margarine blend present in facility kitchen. LPA also

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

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
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 2
Control Number 21-AS-20260212082027
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: 05/11/2026
NARRATIVE
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Continued form 9099...

observed salt and pepper. During investigation, Spanish speaking LPA Cuadra attempted to conduct interviews with four (4) staff. Of the four (4) staff, one declined to interview, one agreed to be interviewed, and two (2) did not respond to LPA’s attempts to interview. During investigation, LPA Coppo conducted interviews. Four (4) out of four (4) staff report that residents can ask for whatever they like as far as food and they then ask the kitchen staff to get it. Four (4) out of four (4) staff report that to the best of their knowledge the facility has never run out of butter or salt and pepper. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Complaint alleges resident call button in disrepair resulting in residents needs not being met. Complainant alleges that resident (R2) urinated on the floor in their bedroom due to not receiving help from staff when using call button pendant. During investigation, LPA observed R2’s call button pendant to not work. LPA pushed call button pendant, waited for 11 minutes, but no staff ever showed up. Additionally, when LPA pushed call button pendant LPA did not hear a sound notification go off or alert to staff. During initial visit to facility, LPA observed call button affixed to the wall behind a television, not easily accessible. During subsequent visit to facility, LPA observed the call button that was affixed to the wall had been moved from behind the television to a more accessible spot on the wall. During investigation, Spanish speaking LPA Cuadra attempted to conduct interviews with four (4) staff. Of the four (4) staff, one declined to interview, one agreed to be interviewed, and two (2) did not respond to LPA’s attempts to interview. During investigation, LPA Coppo conducted interviews. Four (4) out of four (4) staff report that R2 does have incontinence issues but could not remember if R2 had ever urinated on the floor in their room. One staff indicated that R2 does have accidents but did not recall exactly where R2 urinated, commenting that the only problem is when “R2 does not urinate in the toilet.” So, LPA did determine that R2’s pendant was in disrepair, staff did not respond to it, and the call button for the room, at that time, was not easily accessible as it was located behind a television. However, LPA did not obtain a preponderance of evidence showing that the broken pendant resulted in resident’s care need not being met. So, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted with licensee and copy of this report given.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Christi Coppo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/11/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/11/2026
LIC9099 (FAS) - (06/04)
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