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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803428
Report Date: 06/03/2022
Date Signed: 06/27/2022 08:15:59 AM


Document Has Been Signed on 06/27/2022 08:15 AM - 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:MUIR WOOD LLC - SKILLMAN SOUTHFACILITY NUMBER:
496803428
ADMINISTRATOR:SOWLE, SCOTTFACILITY TYPE:
730
ADDRESS:TELEPHONE:
CITY:STATE: ZIP CODE:
CAPACITY:10CENSUS: DATE:
06/03/2022
TYPE OF VISIT:Required - 2 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Bryan BowenTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Cheyenne McCambridge conducted an unannounced Required two year inspection of the facility. LPA McCambridge met with Cheif Operating Officer Bryan Bowen and toured the facility, inside and out.The facility is clean, safe, sanitary, and in good repair. Front and backyard are safe and free from hazards. All passageways are unobstructed. There are no bodies of water on the property. No room commonly used for other purposes is used as a bedroom. All bedrooms have adequate closet and drawer space. The home is maintained at a comfortable temperature. There is an adequate supply of perishable and nonperishable food available. Sharps are kept locked in the chefs closet and toxins are kept locked in laundry room. Medications are kept double locked in staff office.There are carbon monoxide and smoke detectors throughout the facility. There were operable fire extinguishers posted throughout the facility. There are complete first-aid kits located in the facility. Facility understands that the hot water temperature must be maintained within the regulation range of 105 – 120 degrees. There are no firearms on the property. Personal rights and Emergency disaster forms were posted in the sitting area.

The group home is licensed to serve ten clients ages 12-17. Currently in placement are seven male clients. The home operates within the capacity and limitations of the license. LPA McCambridge reviewed client and staff files. Files reviewed are complete and current with required documents.

No Title 22 deficiencies cited this date.
Exit interview conducted a copy of the report was left at the facility.
SUPERVISOR'S NAME: Zaid HakimTELEPHONE: (707) 320-3944
LICENSING EVALUATOR NAME: Cheyenne McCambridgeTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2022
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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