496804122-5-23-2024-21-AS-BMOS-D5QNMW-20240529103546

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496804122
Report Date: 05/23/2024
Date Signed: 05/23/2024 01:31:18 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
04/09/2024 and conducted by Evaluator Marisol Cuadra

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20240409090025

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:	05/23/2024
		UNANNOUNCED	TIME BEGAN:	12:19 PM
MET WITH:	Lisa DiBartolo (Administrative Assistant)		TIME COMPLETED:	01:46 PM

ALLEGATION(S):

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-Personal Rights.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegation and met with Administrative Assistant, Lisa DiBartolo.

The Department received an allegation of Personal Rights. On 4/5/24 resident (R1) told reporting party that another resident (R2) enters their room during the night, punches and stabs them in the stomach. Based on records review, LPA obtained Sonoma County Sheriff’s office report #SD240960118 indicated that on 4/5/24 from the reporting party stating that R1 stated that they had been abused at the facility by another resident (R2). However, there were no injuries consistent with their statement resulting in an unfounded case disposition. The Department have received incident reports dated 3/22/24, 3/31/24, 4/2/24, 4/11/24, 4/19/24, 4/24/24, 4/28/24 and 4/30/24 regarding R1’s behaviors including verbal attempts to commit suicide and medical emergencies due to R1 keeps pulling their catheter out several times.

Continues on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

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-20240409090025

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: 05/23/2024

NARRATIVE

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Continued from LIC9099...

R1’s physician report dated 8/14/2023 revealed that they have a primary diagnosis of delusional cognitive disorder, which it was confirmed with R1’s discharge documents provided that do not indicate any skin condition when assessment was performed during R1’s hospitalization. During LPA’s visit to the facility on 5/2/24, LPA toured the facility, it was observed that R1’s bedroom is located at section A and R2’s bedroom is located at section B of the facility far away from each other. Also, R1 was observed very agitated and actively refusing paramedics and police officer transportation to the hospital after removing their foley catheter out. Based on interviews conducted with facility staff (S1, S2, S3, S4 and S5) and residents in care (R1, R2 and R3), statements indicated that there had been incidents of resident-on-resident aggression unrelated to R1, where the facility’s procedure is to reach out to their physicians to review and adjust medications if needed. Although, there had been incidents of resident-on-resident aggressions, it appears like the facility has followed their program plan by addressing the issues with resident’s responsible parties. A finding that the complaint allegation of personal rights is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Marisol Cuadra	TELEPHONE: (707) 588-5078
LICENSING EVALUATOR SIGNATURE:	DATE: 05/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2024

LIC9099 (FAS) - (06/04)

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