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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 01/29/2025
Date Signed: 01/29/2025 02:24:36 PM

Substantiated


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
07/19/2024 and conducted by Evaluator Shannan Hansen
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20240719150606
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: 47DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Camille Brown, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff do not ensure that a resident's incontinence needs are met
INVESTIGATION FINDINGS:
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While conducting informal office meeting in the Santa Rosa RO, Licensing Program Manager (LPM) Moellers & Licensing Program Analyst (LPA) Hansen delivered findings on the above complaint allegations to Administrator Camille Brown.

Staff do not ensure that a resident's incontinence needs are met– Complaint alleges that the facility is understaffed, resulting in staff not changing resident’s incontinence briefs regularly, causing the resident to wear soaked briefs. Pictures were provided showing resident in two briefs. Complaint also alleges that staff are double briefing and that staff do not clean resident thoroughly when changing their briefs. Complaint alleges that resident has behaviors resulting in a 30-day eviction, but complainant believes that the behaviors are the result of multiple urinary tract infections. Three of five staff interviewed indicated that they have observed, heard of, or have themselves double briefed residents in care with one staff admitting they double briefed to combat frequent urination,
Continued on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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 5
Control Number 21-AS-20240719150606
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: 01/29/2025
NARRATIVE
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Continued from LIC9099
- therefore the allocation Staff do not ensure that a resident’s incontinence needs are met is substantiated, meaning the preponderance of evidence standard has been met, the above allegation is found to be SUBSTANTIATED

Appeal of Rights Given.

The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 21-AS-20240719150606
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/30/2025
Section Cited
CCR
87411(a)
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87411(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs... This requirement was not met as evidenced by:
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Facility Administrator to submit a written response on how they handled the situation by 1/30/2025.
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Bases on pictures provided and staff interviews facility did not comply with above regulation regarding incontinence care needs being met and staff double briefing. This poses an immediate Health and Safety risk to clients in care.
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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.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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
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
07/19/2024 and conducted by Evaluator Shannan Hansen
COMPLAINT CONTROL NUMBER: 21-AS-20240719150606

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: 47DATE:
01/29/2025
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Camille Brown, AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff are not distributing a resident's medication as prescribed
Staff do not ensure that a resident's personal care needs are met
INVESTIGATION FINDINGS:
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While conducting informal office meeting in the Santa Rosa RO, Licensing Program Manager (LPM) Moellers & Licensing Program Analyst (LPA) Hansen delivered findings on the above complaint allegations to Administrator Camille Brown.

Staff are not distributing a resident's medication as prescribed – Complaint alleges that staff are not distributing resident’s medication as prescribed. Complaint alleges that for three days around the first week of July 2024 staff did not distribute resident night dosage of medication and that one time, staff almost distributed a half dose but provided the correct dosage after intervention. Review of prescription orders dated June 25, 2024, July 3, 2024, and July 16, 2024 showed that medication was prescribed in the morning, afternoon and then an additional dose may be given if resident exhibited agitation. A night dosage was not mentioned on the doctor’s orders.

Continue on LIC9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
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-20240719150606
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: 01/29/2025
NARRATIVE
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Continued from LIC9099-C

Staff do not ensure that a resident's personal care needs are met – Complaint alleges that staff are not cleaning and washing resident when toileting and that staff are not washing hands before and after assisting resident with personal care needs, such as brushing teeth. LPA conducted interviews but was not able to confirm instances where staff may not have washed their hands or cleaned/washed residents during personal care assistance.

LPA is unable to obtain supporting evidence to determine staff are not distributing resident’s medication as prescribed or staff are not cleaning and washing resident when toileting, therefore allegations are unsubstantiated. A finding that the complaint allegations of Staff are not distributing a resident's medication as prescribed and Staff do not ensure that a resident's personal care needs are met 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: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 01/29/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/29/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5