496830756-11-2-2023-21-AS-BMOS-CXLPXP-20231115104240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 11/02/2023
Date Signed: 11/02/2023 01:53:26 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/16/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231016084025

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: 54	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Camille Brown, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Resident sustained a fracture due to lack of care from staff

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Camille Brown.

Resident sustained a fracture due to lack of care from staff – Complainant alleges resident (R1) sustained a fractured shoulder due to staff not picking up bathroom rug and R1 tripped over it in the middle of the night. LPA’s interview with staff (S1) & S2 revealed S1 was conducting routine, two-hour rounds of facility residents at approximately 5 AM. This was S1’s second round of R1’s room in less than 2 hours. R1 usually has the lights on, although they were not so S1 turned them on when seeing R1 was walking back to the bed from using the bathroom. S1 greeted R1 and R1 began to turn around by the bed and lost footing and went down hitting their shoulder. S1 went to R1 and called S2 to come help and assess.

Continue on LIC9099-C

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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-20231016084025

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 11/02/2023

NARRATIVE

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911 was called and from the time of the fall until after paramedics left, S1 stayed with R1. S1 indicated R1 informed the paramedics of shoulder pain. LPA obtained paramedics report dated 9/25/2023 at 5:22 am that indicated fall was witnessed and there was good range of motion, as well R1 declined transport to hospital and had POLST on file with comfort measures only.
LPA’s Interview with S2 informed, although the paramedics helped R1 back into bed, the facility does not need assistance helping residents who fall in their rooms back to bed. LPA interviewed the Director of Health Services who confirmed the facility used to call 911 for lift assists with larger residents but discontinued the practice years ago.
The investigation revealed facility incident report dated 10-2-2023 indicates the fall was unwitnessed by S2, but further investigation revealed it was witnessed by S1 who observed R1 turning at their bedside and falling. Therefore, the allegation Resident sustained a fracture due to lack of care from staff is Unfounded. This agency has investigated the complaint and has found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/16/2023 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20231016084025

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: 54	DATE:	11/02/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Camille Brown, Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Staff did not provide resident PRN medication when requested

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Camille Brown.

Staff did not provide resident PRN medication when requested – Complainant alleges PRN (as needed) pain medication was not offered to resident despite complaints of pain. Medication Administration Record (MAR) for R1 dated 10/17/2023 indicates no routine medications prescribed, although over the counter PRN for pain was prescribed on 7/21/2023. LPA’s interview with S2 revealed after paramedics left and R1 was still in shoulder & back pain they offered PRN (Tylenol) as it was on the EMAR but R1 refused. S1 affirmed R1’s decline of PRN offered by S2. R1’s chart notes of 9/25/2023 indicate later that morning R1 was given PRN for pain and then 911 was called for transport again. Although the allegation, Staff did not provide resident PRN medication when requested, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2023

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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