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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 03/30/2023
Date Signed: 03/30/2023 03:02:49 PM


Document Has Been Signed on 03/30/2023 03:02 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:CAMILLE BROWNFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 48DATE:
03/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Talu Faaita, Business Office Manager and Kyle Manford, Director of Environmental ServicesTIME COMPLETED:
03:15 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required - 1 Year inspection of the facility. LPA was welcomed by front desk Melanie Viljoen. LPA met with Business Office Manager Tolu Faaita for today's inspection as Administrator Camille Brown was unavailable. There is a total of 48 residents. There are 13 residents currently on Hospice.

LPA toured the facility on 03/30/2023 at 11:30 AM with Talu Faaita, Business Office Manager (BOM) and Director of Environmental Services Kyle Manford; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The tour of the facility included eight resident apartments, activity rooms, Library, music room, dining rooms, kitchen and outdoor patios & courtyard. Fire Extinguisher was found to be last charged on 12/14/2022 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 10/28/2022. LPA observed 4 out of 4 Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 112.1 degrees F and 118.2 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 resident’s bathrooms while touring facility. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food was found to be handled and stored in a safe manner.

Continued on LIC809C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/30/2023
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 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/30/2023
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LPA initiated a file review of four resident files and five personnel files but were unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.

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: 03/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/30/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2