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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 08/09/2022
Date Signed: 08/09/2022 03:04:57 PM


Document Has Been Signed on 08/09/2022 03:04 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: 48DATE:
08/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Guadalupe Villa-Guerrero, Director of Health ServicesTIME COMPLETED:
03:05 PM
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Licensing Program Analyst (LPA) Shannan Hansen conducted an unannounced case management and met with Guadalupe "Lupe" Villa-Guerrero, Director of Health Services (DOHS). The purpose of this case management inspection is to follow up on a self reported incident report, SOC 341.

CCL received a self report incident report and SOC 341 form on 8/4/2022 reporting on 8/3/2022 staff S1 reported to have witnessed resident R1 trying to hit R2. R2 was able to block R1, and then R1 pushed R2 who fell to the floor. S1 contacted med tech on duty who evaluated finding no injuries. Submitted reports cross reported to Ombudsman and responsible party.

LPA informed there had been previous incidents R1 has had with other residents but no physical contact, as staff has been able to redirect R1. Immediately following incident DOHS began working with R1's POA to arrange a 1 on 1 companion. Prior to this altercation R1's POA was working on finding another placement and at this visit LPA has been informed as of 8/8/2022 R1 has moved.

No deficiencies cited during today's inspection.

New Interim Administrator Camille Brown signed.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/09/2022
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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