496830756-4-12-2024-21-AS-SHAN-D49TB4-20240412143430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 04/12/2024
Date Signed: 04/12/2024 02:34:38 PM

Document Has Been Signed on 04/12/2024 02:34 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 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: 45	DATE:	04/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Lisa Lomeli, Director of Sales & Lupe Villa-Guerrero Director of Health Services		TIME COMPLETED:	02:45 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) Hansen arrived unannounced to conduct an Annual Required - 1 Year inspection of the facility. LPA was welcomed by and met with Director of Sales Lisa Lomeli who is designee as Administrator was unavailable for today’s visit. This senior living community is a full memory care facility. There is a total of 45 residents with 10 residents currently on Hospice. LPA toured the facility on 04/12/2023 at 8:15 AM with Director of Health Services (DHS) Lupe Villa-Guerrero and Director of Environmental Services Kyle Manford; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. The tour of the facility included nine resident apartments, activity rooms, Library, music room, dining rooms, kitchen and outdoor patios & courtyard. Facility serves residents with dementia and has special care plan of operation and programming. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. Food was found to be handled and stored in a safe manner. Facility kitchen has a binder with all resident’s names and their needs. Menu is posted. Food is available for residents any time of the day. Fire Extinguisher was found to be last charged on 12/22/2023 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected by a vender with the last inspection being conducted on 12/22/2023. LPA observed 4 out of 4 Carbon monoxide detectors that were found to be operational during the visit. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 109.4 degrees F and 117.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 9 of 9 resident’s bathrooms while touring facility. Bathrooms contained necessary grab bars and showers contained non-slip floor/mats. Toxins are stored in a locked housekeeping room. Continued on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/12/2024

NARRATIVE

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There was a supply of cleaners, hygiene products and paper products available for residents; although LPA and DHS observed shampoo, conditioner, lotions, spray cans of air freshener, ointments, mouthwash with alcohol, sewing needle & nail polish in multiple resident rooms & bathrooms (see pics) per regulation 87705(f)(2) Care of persons with dementia, such items as alcohol, toxic substances, and disinfectants shall be stored inaccessible to residents with dementia (see LIC809-D). DHS removed items during tour. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Beds were outfitted with mattress pads as required by Title 22 Regulations # 87307 on 4/12/2024 at 9:00AM.
A sample review of five resident & five staff records as well as three resident’s medications was conducted. LPA reviewed resident’s files at 11:15 AM on 4/12/2024 and learned that 5 out of 5 residents have an updated reappraisal/needs & care plan on file as well as medical assessments at this time as required by Title 22 Regulation.

Medications were centrally stored in two locked medication carts in the facility medication room. The Medications of 3 out of 3 residents were found to be given according to physicians’ directions on 4/12/2024 at 10:00 AM. Centrally Stored Medication Record (CSMR) of 3 out of 3 residents were found to be complete and accurate.

LPA conducted a sample reviewed of staff records at 12:30 PM on 4/12/2024 and learned that all facility staff and other individuals who require caregiver background checks have received criminal record clearances or exemptions. In addition, Direct care staff have received the additional training requirements as per Title 22 Regulations and H&S Code. LPA was presented with proof of CPR & 1^st Aid certification for required staff.

Disaster Drills have been conducted monthly in different shifts with the last one being conducted on 3/29/2024. Director of Environmental Services informed in case of disaster and power goes out, facility has a permanent generator that self tests once a week. Camille Brown Administrator Certificate # 6037875740 expires on 7/24/2024.

Appeal of Rights Given.

Continue on LIC809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 04/12/2024 02:34 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/12/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705(f)(2)Care of Persons with Dementia(f) The following shall be stored inaccessible to residents with dementia:(2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidence by:
	Deficient Practice Statement
1 2 3 4	Based on LPA & DHS's observation, the licensee did not comply with the section cited above in 7out of 9 bedrooms inspected contained different items: mouthwash with alcohol, nail polish, spray cans of air freshiner, sewing needle, creams, ointments, shampoo & conditioners in rooms that some are not locked and other residents could enter, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/15/2024
	Plan of Correction
1 2 3 4	1)Facility to send in written plan they understand regulation and how it will be followed by (4/15/2024) 2)Facility will conduct and send proof of staff training of regulation with name of training, staff names, signatures & dates by POC due date of 4/19/2024. to clear citation.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/12/2024

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The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

LPA Hansen is requesting Licensee to update the following documents by 5/7/2024:

LIC 308 Designated -if changes
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan – if changes
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Administrator Certificate
Copy of Certificate of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC809 (FAS) - (06/04)

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