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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 01/07/2025
Date Signed: 01/07/2025 10:42:00 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
10/02/2024 and conducted by Evaluator Marisol Cuadra
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20241002083624
FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:CAMILLE BROWNFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 44DATE:
01/07/2025
UNANNOUNCEDTIME BEGAN:
08:43 AM
MET WITH:Camille Brown (Executive Director) TIME COMPLETED:
10:56 AM
ALLEGATION(S):
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-Resident sustained unexplained bruising while in care.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Cuadra arrived unannounced to conduct a complaint investigation and deliver findings regarding the above allegations and met with Administrator/Executive Director Camille Brown.

The Department received an allegation of resident sustained unexplained bruising while in care. Per reporting party, resident (R1) had bilateral bruising on forearms possible injuries appeared to be inflicted by another. On 4/3/24 the staff was asked about it, but it apparently staff said they asked around and no one saw resident screamed out or anyone go near to them to injure R1. R1 was observed with a band-aid on their forearm so someone had to have seen the bruising. Based on records review, on 10/7/24 LPA was provided by an outside party with pictures supposedly taken on 4/2/24 of R1 with bruising noted in their arms along with an office visit note and e-Prescription dated 4/2/2024 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.
Continued on LIC9099C...
Unsubstantiated
Estimated Days of Completion:
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.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 21-AS-20241002083624
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 01/07/2025
NARRATIVE
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Continues from LIC9099...

Hydroxyzine 25mg tablets were ordered for itching/anxiety. The facility provided R1’s records including physician’s report dated 8/25/23 does not indicate any history of skin condition/breakdown at that time. Although, physician’s order dated 2/26/2024 for Ivermectin 3mg tablets for treatment of scabies. On 3/26/24, R1 had an in-person visit with their physician, who prescribed medications not related to the bruising. However, there were no bruising observed during that in-person visit to their physician. According to facility narrative charting provided to LPA describes that on 3/28/24 R1 was walking down the hall, skin tear and blood was observed on their right forearm, it was cleaned by staff (S1) who placed a band aid and Wellness Director was notified, but the facility did not seek for medical attention for R1, because their policy states that bandage only needed, did not require staff to notify the responsible parties. LPA will address medical attention in a case management due to facility did not seek any further medical attention. On 4/2/24 the facility received a call from R1’s responsible party notifying the facility about R1’s bruising and a bandage that was falling off. On 4/5/24, The Department received SOC341 along with incident reporting suspected physical abuse with unknown suspected abuser. The SOC341 was generated upon request of an outside agency on 4/3/24 after noticing that the facility have not adequately reported R1’s bruising and what appeared to be digging of nails looked like abuse. Based on interviews conducted with outside parties and facility staff, it was determined that on 4/8/24 there was a conference meeting held to discuss the issue. On 4/4/24 staff training records confirmed that staff have received mandated reporting training. Moreover, verbal statements obtained from interviews with involved parties reflects contradictory information and there was no indication to determine the reason of R1’s bruising. According to police records, case #24-3919 has a conclusion of “suspended” status due to other unrelated factors. Based on records review and interviews, LPA is unable to obtain supporting evidence to determine the reasons of R1’s bruising on their forearms. A finding that the complaint allegation occurs of resident sustained unexplained bruising while in care is unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegation is UNSUBSTANTIATED.
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
LIC9099 (FAS) - (06/04)
Page: 2 of 2