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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803428
Report Date: 08/27/2019
Date Signed: 08/27/2019 11:20:48 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MUIR WOOD ADOLESCENT AND FAMILY SERVICESFACILITY NUMBER:
496803428
ADMINISTRATOR:SOWLE, SCOTTFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:10CENSUS: 6DATE:
08/27/2019
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Scott SowleTIME COMPLETED:
11:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Brian Bertoli conducted an unannounced inspection at the facility and met with Scott Sowle. It was discovered during a file review that the facility accepted a client over the age of 17, which is beyond the terms of Muir Woods licensure.

Facility cited for violation of California Code of Regulations, Title 22 Division Six, regulation 80022(k) Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. Based on documentation obtained on 8/9/19 the facility acted beyond the terms of it’s license by admitting C1 (see LIC811 dated 8/27/19) who was over the age of 17.

Exit interview conducted and a copy of the report and appeal rights were provided to the facility.
SUPERVISOR'S NAME: Megan MullenTELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: Brian BertoliTELEPHONE: (408) 406-2118
LICENSING EVALUATOR SIGNATURE:

DATE: 08/27/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2019
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MUIR WOOD ADOLESCENT AND FAMILY SERVICES
FACILITY NUMBER: 496803428
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/27/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/28/2019
Section Cited

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80022(k) Plan of Operation. The facility shall operate in accordance with the terms specified in the Plan of Operation and may be cited for not doing so. This requirement was not met as evidenced by:
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Based on documentation obtained on 8/9/19 the facility acted beyond the terms of it’s license by admitting a client who was over the age of 17 which is an immediate Health, Safety, and Personal Rights Risk to clients in care.
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The facility will conduct training with staff on age exceptions and will submit training summary and staff sign in sheet to CCL. The facility will submit a proposed training date by 8/29/19 and will submit the documentation once the training occurs.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Megan MullenTELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: Brian BertoliTELEPHONE: (408) 406-2118
LICENSING EVALUATOR SIGNATURE:
DATE: 08/27/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/27/2019
LIC809 (FAS) - (06/04)
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