496830756-8-26-2022-21-AS-SHAN-CHNURT-20220826154917

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 08/26/2022
Date Signed: 08/26/2022 03:49:25 PM

Document Has Been Signed on 08/26/2022 03:49 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 CARE		FACILITY NUMBER:	496830756
ADMINISTRATOR:	RODRIGUEZ, BRANDEE		FACILITY TYPE:	740
ADDRESS:	750 NORTH MCDOWELL BLVD		TELEPHONE:	(707) 775-4330
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	80	CENSUS: 50	DATE:	08/26/2022
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	12:35 PM
MET WITH:	Interim Administrator Camille Brown		TIME COMPLETED:	03:50 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 conducted an unannounced case management and met with Camille Brown, Interim Executive Director. The purpose of this case management inspection is to follow up on 2 self reported incident reports and an SOC 341 submitted to Community Care Licensing (CCL).

CCL Received two self reported incident reports and an SOC 341 form on 8/16/2022 reporting first on 8/12/2022 at 4:40 PM staff (S1) reported to have witnessed resident (R1) hit R2 three times in the face. While R1 was being redirected by S1, R1 struck R3 in the shoulder, Medtech was able to step between residents and R1 struck Med tech three times in the back and spit in Med tech’s face. R1 was redirected and given PRN. POA’s and PCP’s were notified.

Second self reported incident report received on 8/16/2022 was regarding an incident that occurred on 8/14/2022 at 5:30 pm where R1 threw dinner plate at R4. While staff was redirecting R1, R1 spit in staffs face. R1 was seen at the ER with new medication orders. Med tech on duty evaluated all residents and no injuries were noted. Submitted reports cross reported to Ombudsman, and later to Petaluma Police Department, and responsible parties notified. Law enforcement report states no crime due to R1’s mental state. Alert monitoring, medication review and change, Care conference, POA arranged a 1:1 companion for a week and has since given notice to facility R1 will be moved out. LPA made copies of records, conducted interviews and made observations.

No deficiencies cited during today’s inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2022

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