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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 12/07/2020
Date Signed: 12/09/2020 02:25:50 PM

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:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:GRALUND, JAMIE EFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 42DATE:
12/07/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jamie Gralund - Executive DirectorTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPAs) Fernandes-Goes & Sarangi conducted an unannounced tele-visit inspection, on 12/9/2020 at approximately 12:00 PM in regards to a case closure notice dated 11/3/2020. LPA is conducting a tele-visit with Executive Director Jamie Gralund in addition to a follow up check on mitigation plan for facility at this time. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. At the time of inspection there were 42 residents.

At approximately 12:00 PM Executive Director stated that individual I1 is not working at the facility and ED understands that an exemption will be required if the staff is to come back to work at the facility and association of the same individual will be necessary.

Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed, or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500.



Verification of removal is complete.

No citations issued during today's visit.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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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