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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 01/07/2025
Date Signed: 01/07/2025 11:05:24 AM

Document Has Been Signed on 01/07/2025 11:05 AM - 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:		CAMILLE BROWNFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 80CENSUS: 44DATE:
01/07/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:43 AM
MET WITH:Camille Brown (Executive Director) TIME VISIT/
INSPECTION COMPLETED:
11:20 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cuadra conducted a case management visit to cite deficiencies discovered during a complaint investigation and met with Administrator/Executive Director Camille Brown.

LPA learned through records review and interviews that facility staff did not seek any medical attention from resident’s (R1) physician after noticing R1’s bleeding on 3/28/24 by facility staff who cleaned and place a bandage on R1’s right arm. According to facility narrative charting as dates progressed, R1 was on a shower schedule of every other day, but R1 refused to shower the morning of 4/2/24. However, the entry was entered late on 4/8/24 at 6:51pm. On 4/2/24 the facility was notified about R1’s bruising noticed by their responsible party, who brought R1 to the urgency care office visit where a physical exam was performed describing scrapes, bruises, and extreme itching with several cuts mainly on right arm, bruises on their lower arms, hands, and wrists; lacerations and skin tears that appear to be from fingernails. Hydroxyzine 25mg tablets were prescribed to R1 for itching/anxiety.

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Appeal rights given. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted with Administrator and a copy of this report was given.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Marisol Cuadra
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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Document Has Been Signed on 01/07/2025 11:05 AM - It Cannot Be Edited


Created By: Marisol Cuadra On 01/07/2025 at 09:10 AM
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: 01/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type A
01/08/2025
Section Cited
CCR
87466

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87466 Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional & social functioning & that appropriate assistance is provided when such observation reveals unmet needs...& brought to the attention of the resident's physician and the resident's responsible person, if any. This requirement has not been met as evidence by:

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Administrator to submit a statement that they understand regulation 87466 and shall be in future compliance ensuring residents are regularly observed for changes as the Plan of Correction (POC) by due date to clear the citation.
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Based on interviews and record review the licensee failed to seek medical attention after observing R1’s injury, which poses an immediate risk to the health and safety of the residents in care.
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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.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Marisol Cuadra
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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