<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 05/14/2026
Date Signed: 05/14/2026 06:31:19 PM

Document Has Been Signed on 05/14/2026 06:31 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
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR/
DIRECTOR:		GRANT HAYWOODFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 80CENSUS: 42DATE:
05/14/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:01 AM
MET WITH:Grant Haywood, AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:45 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
Licensing Program Analyst (LPA) Christi Coppo arrived unannounced to conduct a required Annual inspection and was greeted by concierge. Interim Department of Health Services (DHS) Faveola York worked with LPA until Administrator (Admin) arrived. Administrator Grant Haywood arrived later. Grant Haywood Administrator Certificate 7039094740 expires 8/6/26. All fees are current as of this time. Fee notification given to Admin along with PIN for online payment. Facility currently has 42 residents in care nine (9) of which are currently on hospice.

At approximately 9:30am LPA and DHS toured the building and grounds. The facility was found to be clean and at a comfortable temperature. LPA observed at least a 2 day supply of perishable and 7 day supply of non-perishable food. Food was found to be stored in a safe manner with open items covered and labeled with opened dates present. LPA observed kitchen cleaning products located on a shelf very back of kitchen, away from food preparation. LPA and Director of Dining Services (DDS) discussed adding a cabinet in which to store the disinfectants and cleaning products utilized in the kitchen. DDS will request from Admin immediately. All other cleaning supplies and laundry soaps are located in the laundry room or in cleaning carts, inaccessible to residents in care.

LPA and DHS toured room # 3, #10, and #17. All bedrooms were equipped with lighting, night stand, and chest of drawers. All bedrooms were clean and in good repair. Extra hygiene products and linens were available. Resident bathrooms had required bath mats and grab bars. Water temperature in sinks measured at 116.4 degrees F in room #3, 115.2 degrees F in room #10, and 114.4 degrees F in room #17, all of which are within the allowable range of 105 to 120 degrees F. Facility has common bathrooms used by residents, staff, and guests. Faucets in these bathrooms are turned on by hand sensor. Hot water is an

Continued on 809C...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/14/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 9
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)
Page: 2 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 05/14/2026
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
26
27
28
29
30
31
32
Continued from 809...

option by turning lever all the way back. LPA discussed with Sean Elser Maintenance Director (MD), functionality of faucets and that lever should be set such that the hot water temperature remains within compliance which is a range of 105 to 120 degrees F.

Fire extinguishers were last inspected 11/18/25. Smoke/Carbon Monoxide detectors located throughout the facility are hardwired and serviced by vendor. Vendor annual inspection was last conducted 11/6/25 all systems pass. Facility’s last quarterly disaster drill was conducted on 4.29.26. Facility has a backup generator for use during a power outage. LPA and MD toured outside of facility and emergency shut off sites for water, gas, and electric were all observed. LPA and DHS toured courtyard area. LPA observed two (2) table umbrellas providing shade. Facility has a gazebo in courtyard, but it does not provide shade. LPA and DHS discussed adding a top to the gazebo to provide shade, considering they have a capacity of 80. A shaded gazebo would act to provide much more shaded area. LPA observed video surveillance in resident rooms, signed notices all on file. LPA observed oxygen in use, sign present on door.

At approximately 12:30pm LPA conducted a review of six (6) staff files. Staff do not have the required hours of training completed (deficiency cited, see 809D). Of the files reviewed, two (2) staff started within 12 months, but neither of them had the required numbers of hours and subjects matters completed within the 1st 4 weeks of employment. Additionally, of the six (6) files reviewed, LPA reviewed four (4) Medication Technician (MedTech) files. S2 and S3 MedTechs did not have the required medication training completed on file (deficiency cited, see 809D).

At approximately 2:00pm LPA conducted review of eight (8) resident files. Residents R1, R3, R4, and R5 all had physician reports that were not current (deficiency cited, see 809D)

At approximately 3:00pm LPA and MedTech conducted a spot check of medication and medication records. Medication is centrally stored in a locked room. Facility is required to have a medication management program review completed with a pharmacy every six months, date of last review for facility was 9/19/25 (deficiency cited, see 809D).

Continued on 809C(2)...
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
Page: 3 of 9
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: MUIRWOODS MEMORY CARE
FACILITY NUMBER: 496830756
VISIT DATE: 05/14/2026
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
26
27
28
29
30
31
32
Continued from 809C...

LPA reviewed medications and Centrally Stored Medication log for R7. Two (2) errors were found. Prescription for Zinc Oxide ointment not listed on CMSL (deficiency cited, see 809D). Bubble pack for Escitalopram 20mg had a start date of 4/21/26 and a beginning quantity of 30, but only four (4) pills remain, so bubble pack is missing 2 tabs (deficiency cited, see 809D). Facility does not have tracking system for medications that accidentally fall on floor or such accidents. Additionally, LPA observed pre-pouring of medication (deficiency cited, see 809D).

LPA and Admin discussed Emergency Disaster Plan. Admin confirmed no updates needed.

Updated copies of the following documents were requested for facility file and are to be submitted to CCL within 30 days of this visit:
LIC500- Personnel Report
LIC308- Designation of Responsibility
Liability Insurance

Deficiencies cited from the California Code of Regulations, Title 22, Division 6 of California Regulation and the Health and Safety Code. 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.
NAME OF LICENSING PROGRAM MANAGER: Victoria Bertozzi
NAME OF LICENSING PROGRAM ANALYST: Christi Coppo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/14/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2026
LIC809 (FAS) - (06/04)
Page: 4 of 9
Document Has Been Signed on 05/14/2026 06:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2026 at 05:48 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: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(6)
87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and MedTech record review, the licensee did not comply with the section cited above in that R7 has prescription for zinc oxide that was not listed on the Centrally Stored Medication Log, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
1
2
3
4
Facility to conduct medication training. Training conducted to satisfy deficeincy of HSC1569.69 can count toward satisfying the training required to clear this deficiency. Facility to submit plan to CCL to conduct maintaining proper medication records training for all staff administering medication by plan of correction due date. Training to be completed no later than 5/21/26
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 05/14/2026 06:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2026 at 05:52 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: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.69(a)(1)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S2 and S3 MedTechs did not have the required medication training completed on file, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
1
2
3
4
Facility to conduct medication training. Facility to submit plan to CCL to required medication training for all staff administering medication by plan of correction due date. Training to be completed no later than 5/21/26.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA and MedTech observation, the licensee did not comply with the section cited above in that Bubble pack for Escitalopram 20mg had a start date of 4/21/26 and a beginning quantity of 30, but only four (4) pills remain, so bubble pack is missing 2 tabs, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
1
2
3
4
Facility to conduct medication training. Training conducted to satisfy deficeincy of HSC1569.69 can count toward satisfying the training required to clear this deficiency. Facility to submit plan to CCL to conduct proper medication handling training for all staff administering medication by plan of correction due date. Training to be completed no later than 5/21/26
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 6 of 9
Document Has Been Signed on 05/14/2026 06:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2026 at 05:52 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: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA observation the licensee did not comply with the section cited above in that LPA observed pre=poured medications, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/15/2026
Plan of Correction
1
2
3
4
Facility to self-certify they will cease pre-pouring medications on LIC9098 by plan of corrections due date.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 7 of 9
Document Has Been Signed on 05/14/2026 06:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2026 at 05:52 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: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that S1 and S5 did not have the required number of hours completed, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 05/28/2026
Plan of Correction
1
2
3
4
Facility to complete training for S1 and S5 in the duration and subject matters required per regulation HSC 1569.625(b)(2) by plan of correction due date.
Type B
Section Cited
HSC
1569.69(g)
Other Provisions
(g) Residential care facilities for the elderly licensed to provide care for 16 or more persons shall maintain documentation that demonstrates that a consultant pharmacist or nurse has reviewed the facility’s medication management program and procedures at least twice a year.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that the last consulation was over 6 months ago, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2026
Plan of Correction
1
2
3
4
Facility to arrange for pharmacy consulation review of facility's medication managemnt program by plan of correction due date. Documentation of review to be submitted to CCL.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 8 of 9
Document Has Been Signed on 05/14/2026 06:31 PM - It Cannot Be Edited


Created By: Christi Coppo On 05/14/2026 at 05:52 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: 05/14/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87463(h)(1)
Reappraisals
(h) The licensee shall request that all residents receive an annual routine visit with a licensed medical professional once every twelve months, either in person or by video appointment. (1) Documentation of the annual routine visit, such as a visit summary, shall be added to the resident's record.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on LPA record review, the licensee did not comply with the section cited above in that Residents R1, R3, R4, and R5 all had physician reports that were not current, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/04/2026
Plan of Correction
1
2
3
4
Facility to submit to CCL current physician reports for R1, R3, R4, and R5 by plan of correction due date.
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.
Victoria Bertozzi
NAME OF LICENSING PROGRAM MANAGER:
Christi Coppo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/14/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/14/2026


LIC809 (FAS) - (06/04)
Page: 9 of 9