<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 05/04/2022
Date Signed: 05/04/2022 04:29:26 PM


Document Has Been Signed on 05/04/2022 04:29 PM - 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:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 41DATE:
05/04/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:07 PM
MET WITH:Lupe Villa-Guerrero Director of Health Services TIME COMPLETED:
04:30 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) Hansen arrived unannounced to conduct a Case Management inspection and met with Lupe Villa-Guerrero, Director of Health Services.

LPA is following up regarding a self reported Incident Report and SOC 341 received on April 26,2022 regarding an incident that occurred on April 14, 2022. S1 witnessed R1 being walked down the hall by S3. S3 had there arms under R1's arms and was making R1 walk at a fast pace. R1 began to scream for help. S2 spoke to S3 and explained they should not be rushing R1.

S2 immediately evaluated R1 and no injuries were found. R1 has dementia, shortly questioned afterward by S2 did not recall the incident. Facility did report incident to Ombudsman and per Director of Health Services Local Police conducted an investigation.

Per agency staff S3 has not returned to agency and refused any interviews. Per Dir. of Health S3 is not allowed back at facility.

LPA confirmed S3 has cleared finger prints in the system but is not and never was associated to this facility or the agency S3 was working through.

No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2022
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 1