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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 04/18/2025
Date Signed: 04/18/2025 05:06:17 PM

Document Has Been Signed on 04/18/2025 05:06 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/
DIRECTOR:		KARINA MEDINAFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 80CENSUS: 48DATE:
04/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Karina Medina, AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:15 PM
NARRATIVE
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License Program Analyst (LPA) Hansen arrived unannounced to conduct an Annual Required - 1 Year inspection of the facility. LPA met with Administrator Karina Medina. This single story senior living community is a full memory care facility with 40 apartments. Facility has a fire clearance by Petaluma Fire Department for 80 non-Ambulatory residents and has a Hospice Waiver approved for 20. There is a total of 48 residents with 13 residents currently receiving Hospice services.

LPA toured the facility on 04/18/2025 at 9:45 AM with Administrator and Director of Health Services (DHS) Lupe Villa-Guerrero; 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 12/6/2024 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 11/15/2024. LPA observed 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.

Continue on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 04/18/2025 05:06 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/18/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's & Administrator observation during facility tour, the licensee did not comply with the section cited above finding Janitorial Closet on Side 1 left adjar/open containing toxic cleaning chemicals & storage closet 1 unlocked containing electrical panel by rm 19, accessible to dementia residents, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 04/21/2025
Plan of Correction
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Administration shall provide Acknolegement of regulation and training refresher objectives by 4/21/2025 & provide refresher training for all staff on the requirements of 87309 and will provide proof of completion to CCL by 4/25/2025 in order to clear the deficiency.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2025


LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 04/18/2025 05:06 PM - It Cannot Be Edited


Created By: Shannan Hansen On 04/18/2025 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(c)
Maintenance and Operation
(c) All window screens shall be clean and maintained in good repair.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA & Administrator observation and interview with Regional Dir. of Health & Wellness , the licensee did not comply with the section cited above in finding 26 missing window screen between the inside & exterier of the facility which poses/posed a potential health, safety or personal rights risk to persons in care. Regional Dir infomred they have replaced 14 screens already.
POC Due Date: 05/02/2025
Plan of Correction
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LIcensee to finish replacement of 26 window screens and fix additional damaged screens and submit receipt of repair/replacement to CCL for proof of correction due 5/2/2025 to clear POC.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Bethany Moellers
NAME OF LICENSING PROGRAM MANAGER:
Shannan Hansen
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 04/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/18/2025


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: 04/18/2025
NARRATIVE
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Continue from LIC 809-
Hot water temperature measured between 108.6 degrees F and 115 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 9 of 9 resident’s bathrooms while touring facility. Resident bathrooms had required slip resistant mats and grab bars. Toxins are stored in a locked housekeeping room; although at 10:05am LPA & Administrator observed Janitorial Closet on Side 1 left ajar/open with toxic cleaning chemicals accessible to residents in care (see LIC809-D). During inspection LPA & Administrator observed 26 missing window screens on the inside courtyard & exterior of facility, along with additional damaged screens (see LIC809-D) Regional Director of Health & Wellness informed, there is a screen project with repair service to come out and repair & replace window screens.

There was a supply of cleaners, hygiene products and paper products available for residents. 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 on 4/18/2025 at 10:30 AM.
A sample review of six resident & six staff records as well as two resident’s medications was conducted. LPA reviewed resident’s files at 12:15 PM on 4/18/2025 and learned that 6 out of 6 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 2 out of 2 residents were found to be given according to physicians’ directions on 4/18/2025 at 2:30 PM. Centrally Stored Medication Record (CSMR) of 2 out of 2 residents were found to be complete and accurate.

LPA conducted a sample reviewed of staff records at 1:30 PM on 4/18/2025 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 & 1st Aid certification for required staff.

Disaster Drills have been conducted quarterly in different shifts with the last one being conducted on 3/20/2025. In case of disaster and power goes out, facility has a permanent generator that self tests once a week. Karina Medina Administrator Certificate # 6076069740 expires on 3/11/2027.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 04/18/2025
NARRATIVE
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Continued from LIC809-C

Appeal of Rights Given.

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 5/7/2025:

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
NAME OF LICENSING PROGRAM MANAGER: Bethany Moellers
NAME OF LICENSING PROGRAM ANALYST: Shannan Hansen
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2025
LIC809 (FAS) - (06/04)
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