496804122-9-23-2025-21-AS-BMOS-DLYN6N-20250929101124

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 09/23/2025
Date Signed: 09/23/2025 02:54:08 PM

Unsubstantiated

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
08/26/2025 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20250826101958

FACILITY NAME:	MIRABEL LODGE		FACILITY NUMBER:	496804122
ADMINISTRATOR:	VARSHAVSKY, ALEXANDER		FACILITY TYPE:	740
ADDRESS:	6950 MIRABEL ROAD		TELEPHONE:	(707) 887-1754
CITY:	FORESTVILLE	STATE: CA	ZIP CODE:	95436
CAPACITY:	34	CENSUS: 28	DATE:	09/23/2025
		UNANNOUNCED	TIME BEGAN:	02:02 PM
MET WITH:	Lisa DiBartolo (Administrative Assistant)		TIME COMPLETED:	03:09 PM

ALLEGATION(S):

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-Staff did not assist resident with obtaining medical care in a timely manner.
-Staff did not report incident to appropriate parties.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to delivered findings regarding the allegations listed above and met with Administrative Assistant, Lisa DiBartolo.
There is an allegation regarding staff did not assist resident with obtaining medical care in a timely manner. According to the reporting party, on 8/25/2025 at 1AM, the emergency medical responders (EMS) were called to the facility regarding a resident (R1) needing care. Upon arrival, the EMS team assessed R1 and observed that the resident needed immediate care regarding a respiratory condition, when staff (unknown name) reported that R1 had been in that state of condition for two days, but R1 had not received medical care for two days and the staff could not provide a reason, then R1 was transported to Sutter Hospital Emergency Room for care and it was unknown if the resident was admitted into the hospital. Based on records review, on 8/24/25 a fax was sent to R1’s primary physician advising that R1 was showing signs of being ill, had a temperature of 99.1 degrees, that staff provided R1 with acetaminophen (1,500 mg tablet), and that the party responsible was notified along with a fax confirmation sheet dated 8/24/25 at 10:53:10am been successfully sent to fax # 18008668844.
Continue in LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20250826101958

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: 09/23/2025

NARRATIVE

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Continued from LIC9099...

A second fax was successfully sent to R1’s primary physician on 8/25/25 at 2:05:29pm advising that R1 was in their bed showing signs of sweating, trouble breathing and notifying them of R1’s transportation to Sutter hospital. LPA obtained police records #SD250826005 confirmed information above mentioned regarding staff seeking medical care for R1 with an unfounded resolution. Also, LPA reviewed incident reports submitted to the department, where it was confirmed that the facility submitted an incident report on 8/25/25 regarding R1’s condition. Based on LPA’s observations, records review and interviews conducted with pertinent parties, it was determined that the facility has followed proper protocol regarding seeking timely medical care assistance to R1 and it’s unclear the reasons why the unknown staff told the reporting party that R1 had not received medical care for two days. A finding that the complaint allegation of staff did not assist residents with obtaining medical care in a timely manner is unsubstantiated meaning that 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.

Another allegation of staff did not report the incident to appropriate parties. Per Reporting Party, R1 was transported to the hospital, after they allegedly needed immediate care due to respiratory condition. According to the Reporting Party, unknown staff told them that they had not notified R1's responsible party of their condition. Based on records review, R1’s identification and emergency information form (LIC601) revealed that R1 has listed placement agency and nearest relative person as their responsible parties, which coincides with R1’s physician orders for life-sustaining treatment (POLST) form. Based on LPA’s observations, records review and interviews conducted with pertinent parties it was confirmed that the facility have reported the incident to one out of the two R1’s party responsible listed on file, the findings coincide with police records #SD250826005 obtained, where the case was determined as unfounded after police officers have conducted confidential interviews with pertinent parties. A finding that the complaint allegation of staff did not report the incident to appropriate parties is unsubstantiated meaning that 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.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2025

LIC9099 (FAS) - (06/04)

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