<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 04/04/2023
Date Signed: 04/04/2023 12:43:16 PM

Document Has Been Signed on 04/04/2023 12:43 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: 47DATE:
04/04/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Camille Brown, Administrator andTalu Faaita, Business Office ManagerTIME COMPLETED:
12:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
License Program Analyst (LPA) Shannan Hansen arrived at 8:30 AM to complete an unannounced annual inspection and met with Camille Brown, Administrator. There is a total of 47 residents.

LPA reviewed 5 staff records with all required First aid and CPR certification current. Administrator Certificate was current with an expiration date of 07/24/2024. Centrally stored medication records were reviewed, and LPA conducted 4 staff and 3 client interviews to complete this annual inspection.

No deficiencies cited during today's inspection.


LPA Hansen is requesting Licensee to update and submit the following documents by 4/25/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Proof of Liability Insurance

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2023
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 1