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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 07/24/2023
Date Signed: 07/24/2023 01:39:32 PM

Substantiated


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
05/03/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230503124650
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: DATE:
07/24/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Administrator, Camille BrownTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Facility did not meet residents care needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst Bertozzi arrived unannounced to deliver findings regarding the above complaint allegation and met with Administrator, Camille Brown.

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

Facility did not meet residents care needs – Complaint alleges that resident’s care needs were not met including staff not observing that resident was exhibiting symptoms of a possible Urinary Tract Infection and failing to contact the resident’s doctor to request that resident be tested, not adding teeth brushing assistance to resident’s care plan resulting in resident not receiving assistance and ultimately having cavities, staff not following up on a rash resulting in responsible party having to contact the doctor and get a prescription to treat the rash and staff storing resident’s hearing aid batteries in medication room but not changing the batteries in resident’s hearing aids. Per staff interviews, resident was independent and often

Continued on LIC9099C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
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)
Page: 1 of 6
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
05/03/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230503124650

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: 51DATE:
07/24/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:Administrator, Camille BrownTIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff failed to administer 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.

Staff failed to administer resident's medication as prescribed – Complaint alleges that resident’s medication ran out and the refill had not been delivered. Review of documents revealed that resident did run out of medication, but medication arrived at facility prior to next dose so medication was not missed.

This agency has investigated the complaint alleging Staff failed to administer resident's medication as prescribed. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

Unfounded
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
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)
Page: 2 of 6
Control Number 21-AS-20230503124650
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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"AMENDED" This is an amended version of the original report created on July 24, 2023

Continued from LIC9099

refused assistance. Some staff were unaware that resident wore a hearing aide. Based on document review, facility was requested in writing on December 7, 2022 to add teeth brushing and assistance with hearing aides to the resident's care plan. Per review of resident's care plan, these items were not added. Based on interviews with staff, they were not assisting resident with these items. Evidence obtained during investigation could not determine if facility failed to meet the resident's care needs regarding the UTI or rash.

Based on LPA observations and interviews which were conducted and record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division & Chapter number), are being cited on the attached LIC 9099D.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties.

SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 09/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 6
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
05/03/2023 and conducted by Evaluator Victoria Bertozzi
COMPLAINT CONTROL NUMBER: 21-AS-20230503124650

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: DATE:
07/24/2023
UNANNOUNCEDTIME BEGAN:
09:11 AM
MET WITH:TIME COMPLETED:
01:40 PM
ALLEGATION(S):
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Staff did not ensure meals were made available to resident
Staff did not ensure resident had access to room
Staff did not provide resident with laundry service
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.

Staff did not ensure meals were made available to resident – Complaint alleges that when resident did not show up for meals staff would not come check on them resulting in resident losing weight by missing meals. Per staff interviews, resident was "independent" with Activities of Daily Living like meals but did need reminding at times. Staff did not note any issues with resident not coming to meals. Per Executive Director, there is a designated staff that monitors what residents come to meals and if a resident does not arrive, a caregiver will follow up. Review of resident's Weights and Vital Sign Record does not show a 5 lb or more weight loss, which would prompt staff reaching out to resident's doctor.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
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)
Page: 4 of 6
Control Number 21-AS-20230503124650
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 LIC9099A

Staff did not ensure resident had access to room – Complaint alleges that resident’s door locks automatically and resident was not given a key for three weeks after returning from the hospital resulting in resident having to request access to their room from a staff. Resident didn’t want to leave their room because they were concerned they would not be able to get back in. Staff interviews indicated that residents are given a key when they move in but the keys are frequently misplaced. Facility has multiple keys for the same room in case keys are lost. Care staff have a master key and can open any room for a resident. Interview with staff disputes the three week period as alleged and indicates that resident was given a key when it was brought to staff's attention. Staff denies key being taken from the resident when they left for the hospital, as alleged.

Staff did not provide resident with laundry service – Complaint alleges that resident’s responsible party did resident’s laundry because it was not being done by staff and items were missing. Per staff interview, resident personal laundry is done once per week and laundry is done individually to decrease the possibility of items going missing, adding that there were a lot of "lost and found" clothes due to the items not being marked. Family may do laundry if they prefer.

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 allegation is unsubstantiated
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
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)
Page: 5 of 6
Control Number 21-AS-20230503124650
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/24/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
07/25/2023
Section Cited
CCR
87705(c)(5)(A)
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87705 Care of Persons with Dementia (5) Each resident with dementia shall have an annual medical assessment... and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs. (A) When any medical assessment, appraisal, or
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Facility agrees to conduct an in-service with all staff regarding their Grooming Policy and provide proof of training to CCL no later than POC due date, 7/25/2023.
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observation indicates that the resident’s dementia care needs have changed, corresponding changes shall be made in the care and supervision provided to that resident. This requirement was not met based on record review, This is an immediate risk to health and safety.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Hope DeBenedetti
LICENSING EVALUATOR NAME: Victoria Bertozzi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/24/2023
LIC9099 (FAS) - (06/04)
Page: 6 of 6