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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 10/28/2025
Date Signed: 10/28/2025 02:05:51 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2025 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250904040256
FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:KARINA MEDINAFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 50DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Heather Montgomery, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff are not safeguarding resident's personal belongings
Staff are not providing adequate laundry services to residents in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver investigation findings to the allegations listed above. LPA met with Administrator, Heather Montgomery.

During the course of this investigation LPA conducted 2 facility visits on 9/9/2025 & 10/7/2025 making observations, obtained facility documents, and conducted 11 interviews with staff, residents, and outside parties.
Staff are not safeguarding resident's personal belongings & Staff are not providing adequate laundry services to residents in care - Complainant alleges that relatives have found their loved ones clothing being worn by other residents and their clothing have been missing and never found. As well relatives cannot depend on the staff to wash the residents clothing in a timely manner and return to owner. Interview with staff (S1) revealed an Interim executive director changed the laundry system a few months ago replacing individual staff who did laundry with caregivers doing laundry.
Continue on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 21-AS-20250904040256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 10/28/2025
NARRATIVE
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Continued from LIC9099

Corporate has been informed there has been many problems with this change including needing a specific laundry person as resident cloths are being put in different resident rooms/lost and some being ruined/shrunk. Interviews with S4 & S5 corroborate laundry is being misplaced and some cloths are missing. Outside party, Individual (I1) also indicated there is laundry missing since the change and is not getting back in a timely manner. Interview with resident (R1) revealed they have lost cloths to the facility laundry as well when the laundry was returned items were shrunk, family is now doing all of their laundry. Obtained Laundry Log from 7/26/2025 to 8/21/25 (4 pages) all 4 pages missing filled in columns of either room numbers , washer used, time put in dryer, or dryer used, time finished and by whom. As well, many different staff who handled laundry only a couple staff filled out log completely. New Administrator, Heather Montgomery as of 9/10/2025 confirmed on 10/7/2025 there was a change in the laundry system some months ago and there still seems to be cloths misplaced and lost. The facility is working on implementing the old system. During today's visit 10/28/2025 Administrator informed old system was reinstated on 10/1/2025. It was revealed resident items were not being safeguarded due to facility not having adequate laundry service. Based on LPA's observations and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegations Staff are not safeguarding resident's personal belongingsand Staff are not providing adequate laundry services to residents in careare found to be SUBSTANTIATED.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20250904040256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/28/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/28/2025
Section Cited
CCR
87307(a)(3)(F)
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87307(a)(3)(F) Personal Accommodations and Services: (F) Basic laundry service (washing, drying, and ironing of personal clothing). This requirement is not met as evidenced by :
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New Administrator has reinforced old laundry system with a main staff conducting 5 days a week with NOC shift completing remainder from the day that was not, by laundry staff. And another primary from housekeeping is doing other 2 days regularly. Reinstatement of old laundry system started 10/1/2025.
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Based on interviews, observations, and records reviewed Licensee did not ensure resident laundry was completed, leaving laundry in other residents’ rooms, not finishing laundry in an appropriate time. This poses a potential Health and Safety risk to residents in care.
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POC cleared at visit.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/04/2025 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20250904040256

FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:KARINA MEDINAFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 50DATE:
10/28/2025
UNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Heather Montgomery, AdministratorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Facility is not responding to the family council
Facility did not notify of fee changes per regulation
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Hansen arrived unannounced to deliver investigation findings to the allegations listed above. LPA met with Administrator, Heather Montgomery.

During the course of this investigation LPA conducted 2 facility visits on 9/9/2025 & 10/7/2025 making observations, obtained facility documents, and conducted 11 interviews with staff, residents, and outside parties.

Facility is not responding to the family council- Complainant alleges the facility is not responding appropriately to the family council requests/questions. LPA obtained first family council meeting document of 8/16/2025 indicating concerns and recommendations submitted to Interim Executive Director by family council president. Responses by Interim Executive Director to Family Council President provided on 8/25/2025. Second family council was held on 9/20/2025 and did not have any concerns or comments provided. Therefore there was no response provided by facility. Continued on LIC9099C2
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20250904040256
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 10/28/2025
NARRATIVE
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Continued from LIC9099A

Health and Safety Code Regulations 1569.158 states: Family councils (f) If a family council submits written concerns or recommendations, the facility shall respond in writing regarding any action or inaction taken in response to the concerns or recommendations within 14 calendar days. The facility has submitted over a page of answers pertaining to the questions/concerns provided from the first family council meeting held 8/16/2025 and did not respond to 2nd council meeting as there were no concerns submitted. There was no information obtained that supported that a violation had occurred. Therefore the allegation is Unsubstantiated.

Facility did not notify of fee changes per regulation – Complainant alleges the facility said they would be implementing an increase in their charges for laundry after the family council complained and after having the same fee schedule for over a year and a half. Facility Admission agreement indicates one personal load of laundry per week for everybody's laundry. Agreement also indicates additional loads would be $20.00 per load. Resident Assessments reviewed dated 9/2025 did not show any points for laundry services. Interview with Business Office Manage and Administrator revealed as of 10/28/2025 no family /resident has been charged extra for laundry services, not even when the need arises with soiled bedding or laundry or spills. There was no information obtained that supported that a violation occurred. Therefore the allegation is Unsubstantiated.

Based on the interviews, record/document reviews, and related information obtained during the investigation the allegation's Facility is not responding to the family council and Facility did not notify of fee changes per regulation are UNSUBSTANTIATED, meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5