496830756-7-24-2023-21-AS-HDBI-CUBP59-20230802110021

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:41:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/17/2023 and conducted by Evaluator Victoria Bertozzi

COMPLAINT CONTROL NUMBER: 21-AS-20230517151246

FACILITY NAME:	MUIRWOODS MEMORY CARE		FACILITY NUMBER:	496830756
ADMINISTRATOR:	CAMILLE BROWN		FACILITY TYPE:	740
ADDRESS:	750 NORTH MCDOWELL BLVD		TELEPHONE:	(707) 775-4330
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	80	CENSUS: 51	DATE:	07/24/2023
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Administrator, Camille Brown		TIME COMPLETED:	01:51 PM

ALLEGATION(S):

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Facility failed to meet residents incontinence care needs
Facility staff are not providing basic laundry service in a timely manner
Facility staff are not administering resident's medication as prescribed

INVESTIGATION FINDINGS:

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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegations and met with Administrator, Camille Brown.

During investigation, LPAs conducted interviews, reviewed documents and made observations.

Facility failed to meet residents’ incontinence care needs – Complaint alleges that resident was observed mid-morning with fecal matter in their incontinence brief and bed as well as urine-soaked sheets. Additionally, resident was observed later in the day with a soiled incontinence brief. Staff interview indicated that resident was dry and had a bowel movement while being assisted by caregiver. Interview denied that resident was observed with feces on the bed and indicated that all residents are checked every two hours and assisted with incontinence care, if needed.

Continued on LIC9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230517151246

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MUIRWOODS MEMORY CARE	FACILITY NUMBER: 496830756
	VISIT DATE: 07/24/2023

NARRATIVE

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Continued from LIC9099

Facility staff are not providing basic laundry service in a timely manner – Complaint alleges that resident’s laundry is not completed timely evidenced by resident not having any pants in their closet, only tops. Staff interview indicated that resident had clothes in their closet during alleged incident and denied having to go to the laundry room to get pants.

Facility staff are not administering resident's medication as prescribed – Complaint alleges that resident was not given their noon medication. Interviews and review of the Medication Administration Record was not sufficient to prove or disprove that medication was missed.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegations are unsubstantiated

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Victoria Bertozzi	TELEPHONE: (707) 588-5087
LICENSING EVALUATOR SIGNATURE:	DATE: 07/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023

LIC9099 (FAS) - (06/04)

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