496830756-3-16-2022-21-AS-SHAN-CCKS4L-20220316133254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 496830756
Report Date: 03/16/2022
Date Signed: 03/16/2022 01:33:02 PM

Document Has Been Signed on 03/16/2022 01:33 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 CARE		FACILITY NUMBER:	496830756
ADMINISTRATOR:	RODRIGUEZ, BRANDEE		FACILITY TYPE:	740
ADDRESS:	750 NORTH MCDOWELL BLVD		TELEPHONE:	(707) 775-4330
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	80	CENSUS: 43	DATE:	03/16/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Interim Executive Director Karen Moore, Tolu Faaita Business Office Mgr. & Lupe Villa-Guerrero Director of Health Services		TIME COMPLETED:	01:32 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) Hansen conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and met with Interim Executive Director Karen Moore, Tolu Faaita Business Office Mgr., and Guadalupe Villa-Guerrerro Director of Health Services. There are 43 residents present at the facility with 8 on Hospice. Facility has activities planned for residents during the day. LPA arrived at the facility and had her temperature checked and logged into electronic system. During facility tour on 3/16/2022 with Business Office Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguisher was found to be last charged on 12/7/2021 at the time of the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations on this day at the time of the visit. Toxins are stored in a locked inside housekeeping closed on the hallway. Dangerous items were stored inaccessible to clients. There was a supply of cleaners, hygiene products and paper products available for clients. All resident’s bedrooms have lighting & appropriate furnishings. Hot water temperature measured between 111.7 degrees F and 114.6 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 7 of 7 resident’s bathroom faucets. Residents’ medications are stored and locked in the medication cabinet at med room. Facility has a 30-day supply of medication for residents. Infection Control: Facility has submitted a mitigation program plan that was approved on 5/14/2021. Posters have been placed at entrance, and facility has a station at main entrance with AccuteShield kiosk, hand sanitizer and other items designated for visitors and staff. Staff before coming into work have temperature checked. Continue on 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/16/2022

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Facility has PPE supply stored in the storage area. There has been one new staff hired and new resident's admissions lately which have been tested and cleared before coming into facility. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed in the facility. Residents have also available Facetime, Zoom, and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and acquired N-95 fit testing.

LPA reviewed Licensing Information System (LIS) with Business Office Manager who stated that is all correct except the email address needs to be changed. In addition, LPA advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills have been conducted frequently with a different one conducted each month, the last was fire drills (3/3/2022), every month for different shifts.

LPA was presented with proof of CPR & 1^st Aid certification for staff which files were reviewed.

Administrator Certificate is for Brandee Rodriguez # 6059911740 Exp. 7-12-2023
All staff have received COVID booster vaccinations and exclusively work at this facility.

There were no deficiencies cited at this time.

LPA Hansen is requesting Licensee to update and submit the following documents by 4/1/2022 to SRRO:

LIC 308 Designated

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan for RCFE

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 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

LIC809 (FAS) - (06/04)

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