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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496803428
Report Date: 06/19/2024
Date Signed: 06/19/2024 11:53:45 AM


Document Has Been Signed on 06/19/2024 11:53 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
SANTA ROSA RO, 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: 6DATE:
06/19/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kelli AzevedoTIME COMPLETED:
11:30 AM
NARRATIVE
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On the above date, Licensing Program Analyst (LPA) Cheyenne McCambridge conducted a Case Management visit to discuss issues that came up during a recent investigation, control number 21-CR-20230905113837. LPA met with Director of Operations Kelli Azevedo.
Based on review of documentation submitted by the facility they were missing the visitation policy/plan in the clients' needs and services plan.

LPA provided a copy of the CDSS LIC 625 and a copy of the Title 22 regulations of what is to be included in the clients' needs and services plan.

LPA McCambridge issued a type B deficiency per Title 22 Regulations for section 84068.2 Needs and Services Plan (b)(6).

An exit interview was conducted and Appeal Rights were provided. The LIC809 Evaluation Report and deficiency page were sent to the Director of Operations.
SUPERVISOR'S NAME: Isabel DiegoTELEPHONE: (408) -406-2326
LICENSING EVALUATOR NAME: Cheyenne McCambridgeTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 06/19/2024 11:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405


FACILITY NAME: MUIR WOOD LLC - SKILLMAN SOUTH

FACILITY NUMBER: 496803428

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 06/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2024
Section Cited
CCR
84068.2

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84068.2 Needs and Services Plan (b) The needs and services plan shall identify the child's needs in the following areas: (6) Visitation, including the frequency of and any other limitations on visits to the family residence and other visits inside and outside the facility. This requirement is not met as evidenced by:
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Facility will send updated section of treatment plan to LPA.
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Based on record review this was not included in the clients' needs and services plan which poses an potential health, safety, or personal rights risk to residents in care.
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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: Isabel DiegoTELEPHONE: (408) -406-2326
LICENSING EVALUATOR NAME: Cheyenne McCambridgeTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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