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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 02:10:49 PM

Document Has Been Signed on 03/16/2022 02:10 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:
7077754330
CITY:PETALUMASTATE: CAZIP CODE:
94954
CAPACITY: 80CENSUS: 43DATE:
03/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:36 PM
MET WITH:Tolu Faaita Business Office Manager & Lupe Villa-Guerrero Director of Health ServicesTIME COMPLETED:
02:10 PM
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On 3/16/2022 Licensing Program Analyst (LPA) Hansen made an unannounced visit to this facility regarding an SOC 341 that was submitted to CCL on 3/10/2022 regarding an incident of an assault (slap) from one resident to another at the facility that occurred on 3/8/2022 at 6:15pm.
Facility is full memory care.

Facility reports after dinner caregiver Guadalupe Villia witnessed resident R1 slap R2 in the face. R1 was redirected and escorted to room. Nurse was called to assess R2, no visible injuries noted and Power of Attorney (POA) and Primary Care Provider (PCP) for both residents were contacted. A medication review was requested for R1.

Report was cross reported to Local Ombudsman.

-Dir. of Health Services -Lupe informed another incident with resident R1 like this incident occured back on 10-7-2021. Staff informed this is the only other incident that has occurred since. R1 's PCP may start resident on a different medication. R1 is back at baseline. R1 has had an in person PCP appointment on 3/15/2022 and there were no changes.
R2 did not sustain any injuries and has had a follow up PCP 3/15/2022 as well. PCP discontinued supplements. Dir of Health Services states staff is keeping an watch on R1 & R2 and keeping them in separate dining rooms.
SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
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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