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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496804122
Report Date: 01/26/2024
Date Signed: 01/26/2024 02:59:14 PM


Document Has Been Signed on 01/26/2024 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



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: 23DATE:
01/26/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Alex Varshavsky (Licensee)TIME COMPLETED:
03:14 PM
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Licensing Program Analyst (LPA) Cuadra conducted an unannounced case management and met with Licensee Alex Varshavsky. The purpose of this case management inspection is to follow up on a couple death reports submitted to Community Care Licensing (CCL).

On 1/16/24 CCL received a death report for resident (R1). Per death report, R1 passed away on 1/14/24 at approximate at 2pm while in the hospital. CCL received an incident report notifying CCL of R1's hospitalizations due to signs of congestion. R1 was previously transported to the hospital on 1/2/24 and discharged on 1/3/24. However, based on records review, R1 was not receiving hospice services when they passed away in the hospital. Responsible parties were notified.

Also, on 1/14/24 at approximate 1:00pm, resident (R2) passed away while in the hospital. Per incident report, R2 was not receiving hospice services when they passed away. Responsible parties were notified.

During today's visit, LPA conducted a visit to review records and follow up the unexpected death of R1 and R2. The investigation found the facility followed all regulation and training requirements. However, R1 and R2 were not receiving hospice services and deaths were unexpected so Licensee agreed to submit death certificate to CCL as soon as they receive it.

No deficiencies found during today's inspection. Exit interview was conducted with Licensee and a copy of this report was given.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol CuadraTELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:
DATE: 01/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/26/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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