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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 03/16/2022
Date Signed: 03/16/2022 02:58:31 PM


Document Has Been Signed on 03/16/2022 02:58 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
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:MUIRWOODS MEMORY CAREFACILITY NUMBER:
496830756
ADMINISTRATOR:RODRIGUEZ, BRANDEEFACILITY TYPE:
740
ADDRESS:750 NORTH MCDOWELL BLVDTELEPHONE:
(707) 775-4330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY:80CENSUS: 43DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Director of Health Services Lupe Villa-GuerreroTIME COMPLETED:
02:58 PM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Case Management visit to the facility regarding an incident & SOC 341 report submitted by the facility on 3/11/2022. LPA met with Lupe Guerrero Director of Health Services regarding the incident that occurred on 3/9/2022 at 9:10 pm between Resident (R)1 and (R)2.

LPA interviewed staff, acquired more information, and toured the facility.

Prior to incident R1 has been witnessed rubbing R2's neck. As per facility, dining room server reported observing R2 with hands on R1's neck. Staff was able to separate them and R2 tried to throw chairs and turn over tables. After a few minutes R2 calmed down and went to bed. R2's MD called to rule out a UTI. MD ordered additional meds for R2. R2's wife will assist with a 1:1 companion in the evenings.
There has never been an issue like this with R2. R1 and R2 have been friends since R2 moved in 9/2021. R1 likes to sit with R2 and thinks this is R1's partner and sometimes they hold hands. R1's wife visits 3-4 times a week and daily this week.

R1 continuously tries to sit with R2 but staff redirects R1. Facility is now keeping R1 away from R2.

On this day LPA witnessed R1 standing in dinning room 1 area appearing to search for books. R2 was coming out of room with personal 1 on 1 headed to dinning room 2 after 1 on 1 had applied cream on R2's leg. Both residents appeared to be calm.


No deficiencies cited during today’s visit.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/16/2022
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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