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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 08/20/2024
Date Signed: 08/20/2024 12:18:40 PM


Document Has Been Signed on 08/20/2024 12:18 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: 45DATE:
08/20/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Camille Brown, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Hansen arrived unannounced to conduct a Health and Safety inspection and met with Camille Brown, Administrator. This full dementia facility has 45 residents in care.

Upon arrival on 8/20/2024 at 10:00 AM LPA toured facility and observed 11 staff, facility to be clean and at a comfortable temperature, activities were being conducted in the dining room and there was enough food per regulation. No immediate concerns noted.

There were no deficiencies cited during today’s visit.

SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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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