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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 08/31/2021
Date Signed: 09/01/2021 10:16:09 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210413140230
FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:GRALUND, JAMIE EFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 40DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tolu Faaita - Business Office ManagerTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Neglect/lack of supervision resulted in resident fall and injury.
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analysts (LPAs) Fernandes-Goes & Hansen arrived unannounced for the purpose of closing the investigation and met with Tolu Faaita - Business Office Manager.

On 4/15, 7/7, & 8/25/2021; LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file and observations with staff, and interviews of staff, complainant, family members/POAs (power of attorneys) on 4/14. 4/15. 6/27, 8/17, & 8/25/2021, LPA learned that facility has 32 residents' that have “Fall Concerns” on care plan, 9 residents' that need assistance w/ 4 being 2 people assist, 15 ambulatories; 15 ambulatory w/ assistance; and 9 residents in wheelchair. (Continue LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
This is an official report of an unannounced visit/investigation of a complaint received in our office on
04/13/2021 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20210413140230

FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:GRALUND, JAMIE EFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: DATE:
08/31/2021
UNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Tolu Faaita - Business Office ManagerTIME COMPLETED:
10:05 AM
ALLEGATION(S):
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Insufficient staffing to meet resident's needs
INVESTIGATION FINDINGS:
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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analysts (LPAs) Fernandes-Goes & Hansen arrived unannounced for the purpose of closing the investigation and met with Tolu Faaita - Business Office Manager.

On 4/15, 7/7, & 8/25/2021; LPA Fernandes-Goes toured the facility; conducted interviews; acquired documentation; and made observations of the facility. During documentation review on file and observations with staff, and interviews of staff, complainant, family members/POAs (power of attorneys) on 4/14. 4/15. 6/27, 8/17, & 8/25/2021, LPA learned that facility has 39 residents at this time and still admitting more residents and 4 caregivers during AM & PM shifts w/ 1 med tech and 2 staff at NOC shift.
Continue LIC 9099A-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 6
Control Number 21-AS-20210413140230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/31/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/01/2021
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.In facilities licensed for 16 or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Sec. 87608. This
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Facility agrees to ensure that they will have enough staff at all times according with the number of residents and their needs. Facility to provided Department w/ plan for staffing immediately due to
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requirement is not met as evidenced by: Based on interviews, obs& doc review, facilitydid not comply w/section above on 39out of39 needs of residents which poses an immediate risk for resident in care. Facility has 4 caregivers at AM & PM shift for 39 residents w/ 4 being 2 people assist, and 39 needing assistance w/ daily living.
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concerns of insufficient staffing and no later then POC due date of 9/1/21. Plan should stated how facility will acquire staff and staff schedule for facility w/ addition of staff needed.
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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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 21-AS-20210413140230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 08/31/2021
NARRATIVE
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Residents' care levels range from Level 2 to 6. At this time facility has 4 res. Level 2, 11 res. Level 3; 10 res. Level 4, 9 res. Level 5, and 5 res. Level 6. Per care plans there are 32 res. w/ fall concerns; 26 need some kind of assistance w/ toileting; 29 needs some kind of assistance and 6 total assistance w/ meals; 9 need assistance w/ transfers and 4 of them is 2 people assist; 27 need diaper change; 5 on hospice; 37 need status check 4 times per shift and 3 need 8 times per shift. In regard to shower schedule, facility schedule shows the following for residents Monday AM 10 & PM 3, Tuesday AM 8 & PM 10, Wednesday AM 10 & 3 PM, Thursday AM10 & 0 PM, Friday AM 9 & 8 PM, Saturday AM 6 & 6 PM, Sunday AM 9 & 2 PM; with 4 residents being 2 people assist. Facility has 4 caregivers on shift to conduct showers, status checks, meals, diapers, toileting, grooming and all the other needs that my occur on each shift. During interviews with staff and family members/POAs, LPA learned that there is a concern about facility being understaffed and staff not being able to meet all residents needs. Staff stated that at times caregivers need to attend alone when helping with a 2 people assist resident. In addition, during visit & Brandee R. ED interview on 8/25, executive director (ED) stated that during meeting with families/POAs, she tells the POAs that they are not able to find caregivers and agency are not having staff available and that the family members know about this before they actually move in. During visit on 8/25/21, there were 3 caregiver staff & 1 agency staff with a med tech. In addition, during today's visit on 8/31/2021 at 8:43 AM while LPAs were waiting for office staff to close the complaint investigation resident R2 came into conference room asking for help. Resident R2 had a shirt on, no pants, and a heavy diaper. (pics on file) Resident R2 urinated at the conference room door. LPA walked with resident to medication room. There was no staff from conference room to dining room/medication room. Based on investigation facility has insufficient staffing to meet resident's needs. (see confidential name list, LIC 812s, LIC 809-D) Department is providing facility with updated Home Care Agency.


Continue LIC 809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 4 of 6
Control Number 21-AS-20210413140230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 08/31/2021
NARRATIVE
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According with complaint allegation “Insufficient staffing to meet resident's needs.” there were related observations made during visit. Based on LPAs' observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

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.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 21-AS-20210413140230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 08/31/2021
NARRATIVE
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In addition, facility residents have had innumerous falls w/ some having some kind of injury. Resident R1 on Hospice had a fall that resulted on a broken hip injury that occurred on 3/22/21 AM. Based on LPA interviews and documentation review, LPA wasn’t able to prove or disprove that fall with injury occurred due to neglect/lack of supervision.

A finding that the complaint allegation of “Neglect/lack of supervision resulted in resident fall and injury.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

****Department is requiring a mandatory informal office meeting that will be scheduled.


No deficiencies cited during this inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 08/31/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/31/2021
LIC9099 (FAS) - (06/04)
Page: 6 of 6