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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 09/10/2026
Date Signed: 09/10/2026 09:33:25 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260602225438
FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:GRANT HAYWOODFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 41DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Brenda Mercer, Operations SpecialistTIME COMPLETED:
09:40 AM
ALLEGATION(S):
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Staff mismanaged resident's medications.
INVESTIGATION FINDINGS:
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At approximately 8:20 AM, Licensing Program Analyst (LPA) Robert Frank arrived unannounced to deliver Complaint findings regarding the above allegation and met with Operations Specialist (OS) Brenda Mercer.

During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents. Complaint alleges that staff mismanaged resident’s medication. Witness W1 provided the Department of Social Services with copies of resident R1’s Centrally Stored Medication and destruction records. LPA confirmed the validity of the documents provided by W1. Medications for R1 are ordered in a thirty (30) day cycle. Based on the thirty (30) day cycle the facility will need to order an additional five (5) pills for standard (non-leap day) year. There were two (2) out of cycle orders for Medication-1 (Med-1). On 3/10/2026 the facility’s pharmacy filled an order for twelve (12) Med-1 pills. On 4/15/2026 the facility’s pharmacy filled an order for six (6) Med-1 pills.

Continued on 9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
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 5
Control Number 21-AS-20260602225438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/10/2026
NARRATIVE
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...Continued from 9099

According to pharmacy staff member witness 2 (W2) all out of cycle orders are placed by the facility. Review of Medication Administration Records (MARs) do not show any missed or double doses of Med-1. LPA interviewed staff members S2 and S3. Neither staff member was able to state exactly why the additional pills were ordered. Additionally, correspondence from staff member S1 in reference to Med-1 states, “In some cases, variances can also occur due to factors such as medication handling, including potential waste, though we do not have documentation confirming this in this instance.” Based on LPA’s interviews and record review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (CCR), Title 22, Division 6 Chapter 8, 87465(a)(4) are being cited on the attached 9099D. As the facility has been previously cited for this deficiency on 5/14/2026, a Civil Penalty of $250 is being assessed.
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20260602225438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/11/2026
Section Cited
CCR
87465(a)(4)
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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed...by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
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Facility to update its Medication Administration plan to ensure that all non-cycle medication orders are recorded. This record should show who, and why a non-cycle medication was ordered. Additionally, facility is to retrain all Medication Technicians in Medication Management record keeping.
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Based on interview & record review, the licensee did not comply with the section cited above in that facility staff cannot explain why thirteen (13) pills of Med-1 were ordered out of cycle which poses an immediate health, safety or personal rights risk to persons in care.
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Proof of training and updated plan to be sent to Community Care Licensing by POC due date of 9/11/2026.
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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: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/02/2026 and conducted by Evaluator Robert Frank
COMPLAINT CONTROL NUMBER: 21-AS-20260602225438

FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:GRANT HAYWOODFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE:CAZIP CODE:
94954
CAPACITY:80CENSUS: 41DATE:
09/10/2026
UNANNOUNCEDTIME BEGAN:
08:20 AM
MET WITH:Brenda Mercer, Operations SpecialistTIME COMPLETED:
09:40 AM
ALLEGATION(S):
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Staff does not ensure med techs are trained.

Staff does not communicate with resident's responsible party.
INVESTIGATION FINDINGS:
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During the course of the investigation LPA conducted multiple facility visits, conducted interviews, collected and reviewed documents.

Complaint alleges that the facility does not ensure that Medication Technicians (Med-Techs) are trained. The RP states that, “the facility has a med tech who, as of the 5/14/2026 Department of Social Services inspection, was not fully trained.” On 5/14/2026 during the annual inspection, the facility was cited for two (2) Med-Techs not having the required medication training. The plan of correction for this deficiency was for Medication Administration training for all Med-Techs. The facility completed the training and the deficiency was cleared. The facility cannot be cited twice for the same deficiency. During the investigation LPA confirmed that the six (6) staff members currently administering medications have completed their initial and annual training requirements. So, 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. Continued on 9099A-C...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 21-AS-20260602225438
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/10/2026
NARRATIVE
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...Continued from 9099-A

Complaint alleges that the facility does not communicate with resident’s responsible party. California Code of Regulations, Title 22, Division 6, Chapter 8, Article 4 Operating Requirements, 87211 reporting requirements states: (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, in route to or from a hospital, or visiting away from the facility. (B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision. (C) The use of an Automated External Defibrillator. (D) Any incident which threatens the welfare, safety or health of any resident, such as psychological abuse of a resident by staff or other residents, or unexplained absence of any resident. LPA reviewed resident R1’s admission agreement and their individual service plan and did not see any additional communication requested regarding resident R1. LPA requested from the facility a copy of all communication between the facility and resident R1’s responsible party from 5/1/2026 to 6/4/2026. LPA observed numerous emails between the facility and resident R1’s responsible party. So, 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.

Exit interview conducted. Copy of report, LIC-9099, LIC-9099-C, LIC-9099D, LIC-421FC, Plan of Corrections, Appeal Rights, LIC-9099A and LIC9099A-C discussed and provided to OS Brenda Mercer. Signature on form confirms receipt of documents.

SUPERVISORS NAME: Victoria Bertozzi
LICENSING EVALUATOR NAME: Robert Frank
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5