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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 03/14/2023
Date Signed: 03/14/2023 11:28:19 AM


Document Has Been Signed on 03/14/2023 11:28 AM - 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:CAMILLE BROWNFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 47DATE:
03/14/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Camille Brown Administrator & Lupe Villa-Guerrero Director of Health ServicesTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Camille Brown, Administrator & Guadalupe Villa-Guerrero Director of Health Services. The purpose of this case management inspection is to follow up on a self reported incident report submitted to Community Care Licensing (CCL) on 3/6/2023.

CCL received a self reported incident report reporting on 3/2/2023 at approximately 10:30 AM of resident (R1) possibly ingesting R2's medication when staff (S1) turned around. R1 was monitored for 48 hours without any adverse side effects. All appropriate parties were contacted.

During today's inspection LPA was informed R1 continues to remain at baseline. LPA toured the facility, obtained medical documents and training documents.

No deficiencies cited during today's inspection

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/14/2023
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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