496830756-5-18-2021-21-AS-CFGS-C35V2E-20210518160301

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 05/17/2021
Date Signed: 05/18/2021 04:03:19 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 CARE		FACILITY NUMBER:	496830756
ADMINISTRATOR:	GRALUND, JAMIE E		FACILITY TYPE:	740
ADDRESS:	750 NORTH MCDOWELL BLVD		TELEPHONE:	(707) 775-4330
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	80	CENSUS: 37	DATE:	05/17/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Tolu Faaita - Business Office Manager		TIME COMPLETED:	04:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with staff Guadalupe Villa-Guerrerro and Business Office Manager Tolu Faaita. There are 37 residents present at the facility. Facility has activities planned for residents during the day. LPA arrived at the facility and had her temperature checked and logged into system. During facility tour on 5/17/2021 with Business Office Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/2020 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked inside housekeeping closed on the hallway. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Infection Control: Facility has submitted a mitigation program plan that has been approved. There is a need for updating staff responsible as infection control lead. Posters have been placed at entrance, and facility has a station at main entrance with AccuteShield kiosk, hand sanitizer and other items designated for visitors and staff. Staff before coming into work have temperature checked.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

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: MUIRWOODS MEMORY CARE	FACILITY NUMBER: 496830756
	VISIT DATE: 05/17/2021

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Facility has PPE supply stored in the storage area. There has been one new staff hired and new resident's admissions lately which have been tested and cleared before coming into facility. Residents’ medications are stored and locked in the medication cabinet at med room. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed in the facility. Residents have also available Facetime, Zoom, and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and acquired N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with Business Office Manager who stated that is corrected and updated except that facility has a new administrator at this time. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted frequently with the last one on 4/2021.

In addition, LPA follow up on a SOC 341 that occurred on 5/5/2021. (see LIC 812)

LPA Fernandes-Goes is requesting licensee to update the following documents by 5/31/2020 and submit to RO Rohnert Park:

LIC 309
LIC 500
LIC 610
LIC 610ES
LIC 308
Copy of Liability Insurance certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2021

LIC809 (FAS) - (06/04)

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