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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 07/07/2021
Date Signed: 07/07/2021 03:25:37 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:GRALUND, JAMIE EFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 37DATE:
07/07/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Tolu Faaita - Business Office ManagerTIME COMPLETED:
12:00 PM
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Licensing Program Analyst's Fernandes-Goes and Hansen conducted an unannounced case management and met with Tolu Faaita Business Office Manager & Lupe Villa-Guerrero -Med Tech.. The purpose of the case management visit was to obtain additional information regarding SOC 341 submitted to the Regional Office by the facility on 6/9/2021 for R 1, a second on 6/23/2021 submitted by R 2 and a third on 6/30/2021 submitted by R 3.

LPA's interviewed staff, acquired more information, and toured the facility.

In addition, facility Corporate Director Denise Munoz contacted the Department informing that on 4/22/2021 there was a change of administrator. It has been indicated that Brandee Rodriguez has assumed administrator duties since May 11, 2021. New administrator has no active CA administrator certificate. LPA Fernandes-Goes contacted facility through an official letter on 5/12 & 6/11/2021 regarding this matter with due dates. LPA also contact facility and spoke with Tolu Business Director on 6/18/2021 and Denise Munoz (returning a call) on 6/24/2021 and 6/25/2021 - left a message and requested a call back - no call back.

At this time facility is in non-compliance due to not having a qualified administrator as per Title 22 Regulations # 87405(a). Department is requesting proof of pending administrator certificate application to be submitted to RO Rohnert Park by July 14th, 2021 in order for facility to avoid citation.


No deficiencies cited during today’s visit.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:

DATE: 07/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/07/2021
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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