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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 08/01/2025
Date Signed: 08/01/2025 10:09:48 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
06/30/2025 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250630160009
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: 30DATE:
08/01/2025
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Alex Varshavsky (Licensee)TIME COMPLETED:
10:24 AM
ALLEGATION(S):
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-Personal Rights.
-Facility staff did not follow physician care orders.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and was greeted by staff Teresa Astudillo. Licensee Alex Varshavsky and Administrative Assistant, Lisa Dibartolo via phone who gave authorization to staff to sign the report.

The Department received an allegation of personal rights. Per Reporting Party, on 6/27/25, resident (R1) was observed to be assisted by staff (S1) who entered the room and made an inappropriate comment to R1, when S1 was about to use prescribed gait belt remarked in Spanish “Oh, ya es hora de amarrarle? which translates to: “Oh, is it time to tie them up?”. Approximately 25 minutes later, R1 requested assistance to another staff member (S2) to get out of bed, S2 entered the room and without announcing their intentions proceeded to pulled R1’s legs, S2 did not acknowledge R1’s request to wait, lifted them by their affected arm, stood them upright, used their legs to push R1’s lower limbs toward a wheelchair and ignored once again R1’s grunted in discomfort as they were placed into the wheelchair. S2 left the room without any further comment or assessment to ensure that R1 was fine. Continue on LIC9099C...
Substantiated
Estimated Days of Completion: 90 days
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
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-20250630160009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122
VISIT DATE: 08/01/2025
NARRATIVE
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Continued from LIC9099...

On 7/9/25, LPA conducted a 10-day visit to the facility, made observations, obtained pertinent records and conducted interviews with staff. During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 reached out to another staff (S2) and told them in Spanish "ayudame con esta", which translates to "help me with this" not referring to resident's name. Once S2 came to the resident’s room, both caregivers initiated the transfer without communicating their intentions to the resident. Upon LPA’s inquiry about both staff not communicating with R2 their intention of transferring R2 from their wheelchair to their bed, their response was that R2 was non-verbal, but they stated that R2 could hear us perfectly. However, they never communicate with R2. Based on staff training records for both caregivers it indicates that staff have received personal rights training, including the dignity of residents and personal care with residents’ transfers within the last year. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

Another allegation of facility staff did not follow physician care orders. The Reporting party stated that on 6/27/25, R1 was observed to be transferred using one-person assist by staff (S1), S1 lifted R1 by their upper extremity, which R1 has repeatedly identified as a source of pain. Despite doctor’s order to use a gait belt, S1 continue to use extremity during transfers, these instructions do not appear to have been followed. On 7/9/25, During the visit, LPA requested S1 to demonstrate how do staff were trained to properly transfer a resident who needs two-person assistance. S1 selected resident (R2) who was in the common area in their wheelchair with other residents watching tv. S1 initiated pushing R2's wheelchair towards their bedroom without notifying R2 of the reasons why they were been transferred to their room, then S1 reached out to another staff (S2) to help with transfer. Once S2 came to R2’s room, both caregivers initiated the transfer without communicating their intentions to the resident, wheelchair was not positioned near nor parallel to the bed, both lifted the resident from their wheelchair and threw them to the bed by pushing their legs with their foot and not even holding their head to prevent them from possibly hitting the wall.

Continue on LIC9099C...

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 21-AS-20250630160009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122
VISIT DATE: 08/01/2025
NARRATIVE
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Continued from LIC9099C...

After the demonstration was complete, LPA inquired if they ever use a gait belt for transfers and they replied to no. According to both staff (S1 & S2), neither of them use gait belts nor use the hoyer-lift machine because they don't like it. Based on records review, LPA was provided with a list of residents in care and two assignment sheets dated 7/3/25 with a total of six residents (R2, R3, R4, R5, R6 & R7) that need two-person assistance. Staff training records for both caregivers revealed that staff have received transfer training techniques within the last year. LPA requested the facility’s transfer protocol as well as gait belt procedures, but the Administrative Assistant stated that they don't have one, but they started drafting one to train staff as soon as possible. LPA reviewed R1’s file, which revealed some contradictory information between the register of facility residents (LIC9020 dated 7/1/25 where it describes R1 as ambulatory status. However, the records review of the incident report dated 6/2/25 indicates that on 5/27/25 R1 was found on the floor in their room, after them attempting to transfer themselves from bed to wheelchair and fall. According to the administrative assistant, R1 walks while on a day program, but it is very unsafe when they use their walker, so they need a wheelchair. Although, their physician report (LIC602) needs to be updated to reflect the ambulatory status change. According to R1’s care plan dated 9/29/24, there is an order for a wheelchair as of 7/25/24, their emergency book from placement agency dated 4/11/25 confirmed the use of gait belt needed as an assistive device which needs to be used to help safely transfer or assist with sitting/standing to R1. Furthermore, there is a doctor's order dated 12/20/24 that confirms "daily use of gait belt, walker for home exercise program to tolerance”. However, R1’s care notes about assistance do not indicate the use of gait belt for R1 as prescribed by their doctor. Per administrative assistant, the gait belt is not necessary for R1 because they are able to stand and sit without it. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. **Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months. 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 the Administrative Assistant.

Exit interview conducted with the Administrative Assistant via phone and copy of this report was given.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 21-AS-20250630160009
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MIRABEL LODGE
FACILITY NUMBER: 496804122
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/01/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/02/2025
Section Cited
HSC
1569.269(a)(1)
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Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other people. This requirement has not been met as evidence by:
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The facility will conduct all staff training regarding personal rights. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date.
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Based on LPA’s observations and interviews with staff, the facility staff assisted residents in care using inappropriate comments and not notifying the residents of their intentions when performing transfers, which poses an immediate risk to the health and safety of clients in care.
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Deficiency Dismissed
Type A
08/02/2025
Section Cited
CCR
87465(c)(2)
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Type A - 87465 (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by:
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The facility will conduct all staff training regarding use of assistive devices & postural support management. Training subject, date of training and signed attendance forms to be submitted to CCL by POC due date.
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Based on records review and interviews with staff, there is a written order from a physician dated 12/20/24 indicating the need for gait belt shall be utilized daily to assist R1 with transfers, but staff (S1 & S2) interviews revealed that they do not use gait belts with none of residents in care, which poses an immediate risk to the health and safety of clients in care
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**Civil Penalty assessed in total amount of $250.00 for repeated violation within 12 months.
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: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4