496830756-11-13-2023-21-AS-BMOS-CXLQJF-20231115111240

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 11/13/2023
Date Signed: 11/13/2023 02:21:04 PM

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
08/15/2023 and conducted by Evaluator Shannan Hansen

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20230815133258

FACILITY NAME:	MUIRWOODS MEMORY CARE		FACILITY NUMBER:	496830756
ADMINISTRATOR:	CAMILLE BROWN		FACILITY TYPE:	740
ADDRESS:	750 NORTH MCDOWELL BLVD		TELEPHONE:	(707) 775-4330
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	80	CENSUS: 54	DATE:	11/13/2023
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Camille Brown, Administrator & Lupe Villa-Guerrero, Director of Health Services		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Residents' needs are not being met
Facility is not handling resident's incontinence care needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegation listed above. LPA arrived unannounced on this day for the purpose of delivering findings of the above allegations. LPA met with Administrator, Camille Brown & Lupe Villa-Guerrero, Director of Health Services.

Residents' needs are not being met – Complainant alleges when resident (R1) moved into facility they forgot their toothbrush and toothpaste. Family realized this two weeks later and asked staff how they handle this situation, staff allegedly replied it is family’s responsibility to bring these items and if the resident didn’t have them, staff don’t brush their teeth. On 8/17/2023 LPA was informed by Director of Health Services Guadalupe Villa-Guerrero that residents are suppose to bring their own hygiene products but if they don’t, the facility has back up supplies and will provide to the residents and then inform the family of the need. LPA’s file review of care plan indicates R1 only requires stand by assistant with grooming.
Continue on LI9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20230815133258

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: 11/13/2023

NARRATIVE

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LPA’s interview with R1 and medical professional (physical therapist) revealed, R1 brushes their own teeth regularly. Although the allegation, Residents’ needs are not being met, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated.

Facility is not handling resident's incontinence care needs- Complainant alleges R2 was yelling roommate had defecated and for at least two hours staff did not come to help. Complainant also alleges when staff came by was told they didn’t have time to help. When LPA conducted interview with reporting party, information regarding time frame was not consistent with complaint and was unable to get any specific times or staff names. LPA conducted record reviews and both R2 & R3 have diagnoses of dementia. LPA interviewed R2 who could not recall the incident. Staff interview indicated that R3 has not had any specific incidences of incontinence problems and indicated that all residents are checked every two hours and assisted with incontinence care, if needed. Although the allegation, Facility is not handling resident’s incontinence care needs, may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation, did or did not occur, therefore the allegation is Unsubstantiated

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:	DATE: 11/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2023

LIC9099 (FAS) - (06/04)

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