Inspection Reports for MuirWoods Memory Care

The visit was an unannounced case management inspection conducted to review the facility's compliance and to follow up on the administrator change process.

The Interim Executive Director has been at the facility since 09/02/2025 and is in the process of providing required documents for administrator change. No citations or deficiencies were issued during this visit.

Unannounced Health and Safety inspection conducted as part of Case Management - Health Checks.

The facility was found to be clean, at a comfortable temperature, with no exits obstructed and sufficient food per regulation. No deficiencies were cited during the visit.

The visit was an unannounced subsequent follow-up inspection conducted to evaluate the facility after an initial visit on 2025-03-20, focusing on case management and incident review.

The Licensing Program Analyst conducted interviews and observations during the visit and found no citations or deficiencies during this follow-up inspection.

The inspection was an unannounced Annual Required - 1 Year inspection conducted to evaluate compliance with licensing requirements at the memory care facility.

The facility was generally found to be clean, safe, and in compliance with many regulations including food safety, medication administration, and staff training. However, deficiencies were cited related to unlocked storage of toxic chemicals accessible to residents and missing/damaged window screens, posing health and safety risks.

The visit was conducted as a Case Management regarding a self-reported incident report and SOC 341 received on 2025-03-18 concerning an alleged sexual assault at the facility.

The Licensing Program Analyst met with the Director of Health Services, obtained documents, and no citations were given during the visit.

The visit was triggered by a complaint of an alleged sexual assault reported by the facility. No citations or deficiencies were issued during the investigation.

The visit was an informal office meeting to discuss a civil case judgement determined in August 2024, address any solvency concerns of the facility, and deliver complaint findings related to complaint 21-AS-20240719150606.

The administrator informed there were no concerns regarding the facility's financial solvency. The meeting also covered the findings of the referenced complaint.

Complaint 21-AS-20240719150606 findings were delivered during the meeting.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-07-19 regarding inadequate incontinence care, medication distribution, and personal care needs at Muirwoods Memory Care Facility.

The complaint that staff did not ensure a resident's incontinence needs were met was substantiated, with evidence of understaffing and double briefing posing immediate health and safety risks. Allegations that staff were not distributing medication as prescribed and not meeting personal care needs were unsubstantiated due to lack of supporting evidence.

The complaint was substantiated for failure to meet residents' incontinence needs due to understaffing and improper care practices. The allegations regarding medication distribution and personal care needs were unsubstantiated.

The visit was a case management inspection conducted to cite deficiencies discovered during a complaint investigation regarding failure to seek medical attention for a resident's injury.

The facility failed to seek medical attention for resident R1 after staff noticed bleeding and injuries, posing an immediate risk to resident health and safety. Deficiencies were cited under California Code of Regulations, Title 22, Division 6.

The visit was triggered by a complaint investigation. The deficiency involved failure to seek medical attention for resident R1 after noticing bleeding and injuries. The deficiency poses an immediate risk to resident health and safety.

The inspection was an unannounced complaint investigation triggered by an allegation that a resident sustained unexplained bruising while in care.

The investigation found contradictory information and insufficient evidence to determine the cause of the resident's bruising. The complaint was deemed unsubstantiated as there was no preponderance of evidence to prove or disprove the alleged violation.

The complaint alleged that a resident (R1) had bilateral bruising on forearms possibly inflicted by another. Despite photographs, medical records, staff interviews, and police records, no conclusive evidence was found to substantiate the allegation. The case was closed with an unsubstantiated finding.

The inspection was an unannounced Health and Safety inspection conducted as part of Case Management - Health Checks.

The facility was found to be clean, at a comfortable temperature, with adequate staffing and sufficient food. No deficiencies were cited during the visit.

An unannounced Annual Required - 1 Year inspection was conducted to evaluate compliance with regulations at the memory care facility.

The facility was generally found to be clean, safe, and compliant with regulations including food safety, fire safety, and resident care plans. However, a deficiency was cited for storing items such as mouthwash with alcohol, nail polish, and other potentially hazardous substances accessible to residents with dementia.

Unannounced complaint investigation visit triggered by allegations that staff did not prevent outbreaks of scabies and COVID-19 at the facility.

The investigation included three site visits, document reviews, and staff/witness statements. Facility management followed appropriate COVID-19 protocols and isolated positive residents. No evidence was found to substantiate a scabies outbreak. The allegations were determined to be unsubstantiated.

Complaint was unsubstantiated based on lack of preponderance of evidence to prove or disprove the allegations regarding scabies and COVID-19 outbreaks.

The inspection was an unannounced complaint investigation conducted in response to allegations of insufficient staffing to meet residents' care needs and inadequate staff training at Muirwoods Memory Care Facility.

The investigation found no preponderance of evidence to substantiate the allegations. Staffing levels were confirmed sufficient, laundry and hygiene needs were met, and staff training records showed compliance with required dementia care training. The allegations were determined to be unsubstantiated.

The complaint investigation addressed allegations of insufficient staffing leading to unmet resident care needs, including laundry and hygiene, and claims that staff lacked adequate training resulting in unnecessary hospital transfers. Both allegations were found unsubstantiated based on interviews, observations, and record reviews.

The inspection was an unannounced complaint investigation visit triggered by complaints alleging that residents' needs were not being met and that the facility was not handling residents' incontinence care needs.

The investigation found no preponderance of evidence to substantiate the allegations. Interviews and record reviews indicated that residents' needs were being met and incontinence care was provided as required, resulting in the allegations being unsubstantiated.

The complaint included allegations that a resident was not provided with toothbrush and toothpaste and that staff did not respond timely to incontinence care needs. The investigation included interviews with residents, staff, and review of care plans and records. Both allegations were found unsubstantiated due to lack of evidence.

The visit was an unannounced complaint investigation regarding allegations that a resident sustained a fracture due to lack of care from staff and that staff did not provide resident PRN medication when requested.

The investigation found the allegation of a resident sustaining a fracture due to lack of care was unfounded, as the fall was witnessed and appropriate care was provided. The allegation that staff did not provide PRN medication was unsubstantiated due to insufficient evidence.

The complaint investigation was triggered by allegations that a resident (R1) sustained a fractured shoulder due to staff not picking up a bathroom rug, causing a fall, and that staff did not provide PRN pain medication when requested. The fracture allegation was found to be unfounded, and the medication allegation was unsubstantiated.

This was an unannounced Case Management Visit to amend a previously issued report dated 07/24/2023 due to an incorrect date reference.

The report was amended and signed on 09/12/2023. No citations or deficiencies were issued during this visit.

The inspection was an unannounced complaint investigation visit triggered by complaints alleging that the facility did not meet residents' care needs, failed to administer medication as prescribed, and other resident care concerns.

The investigation substantiated that the facility did not meet residents' care needs, including failure to add teeth brushing assistance and hearing aid care to a resident's care plan. The complaint alleging failure to administer medication was found unfounded. Other allegations regarding meals, room access, and laundry service were unsubstantiated due to insufficient evidence.

The complaint investigation was substantiated for failure to meet residents' care needs related to care plan omissions and assistance. The medication administration allegation was unfounded. Allegations about meals, room access, and laundry service were unsubstantiated due to lack of preponderance of evidence.

Unannounced complaint investigation visit conducted due to allegations received on 2023-05-17 regarding failure to meet residents' incontinence care needs, untimely laundry service, and medication administration issues.

The investigation included interviews, document reviews, and observations. The allegations were found to be unsubstantiated due to insufficient evidence to prove or disprove the claims.

Complaint allegations included failure to meet residents' incontinence care needs, untimely laundry service, and failure to administer medication as prescribed. The investigation found no preponderance of evidence to substantiate these allegations.

An unannounced annual inspection was conducted as part of the case management annual continuation to evaluate compliance with licensing requirements.

No deficiencies were cited during the inspection. Staff records, administrator certification, medication records, and interviews were reviewed and found compliant.

The inspection was an unannounced Annual Required - 1 Year inspection of the Muirwoods Memory Care Facility conducted by the License Program Analyst.

The facility was found to be clean, safe, and in compliance with regulations including fire safety, food storage, and environmental conditions. No deficiencies were cited during the inspection, though the medication review was not completed and will be conducted at a later date.

The inspection was an unannounced case management follow-up visit to review a self-reported incident involving a resident possibly ingesting another resident's medication.

The resident who possibly ingested the wrong medication was monitored for 48 hours without adverse side effects and remains at baseline. No deficiencies were cited during the inspection.

The visit was triggered by a self-reported incident on 3/2/2023 involving a resident possibly ingesting another resident's medication. The incident was monitored and no adverse effects were found.

The inspection was an unannounced case management visit to follow up on an anonymous complaint regarding laundry piling up outside of the laundry room.

The Licensing Program Analyst observed multiple bags of laundry piled outside the laundry room but was informed the facility is short on housekeeping staff and has hired a vendor to assist with laundry. The laundry issue was resolved prior to the analyst leaving. No deficiencies were cited during the inspection.

The visit was triggered by an anonymous complaint about laundry piling up outside the laundry room. The complaint was addressed and resolved during the inspection.

The inspection was an unannounced case management follow-up visit to review three self-reported incident reports submitted to Community Care Licensing on 9/9/2022 and 9/22/2022.

The inspection found that residents involved in incidents were appropriately managed with hospitalizations and follow-ups. No deficiencies were cited during the inspection.

The inspection was an unannounced case management visit to follow up on two self-reported incident reports and an SOC 341 form submitted to Community Care Licensing.

The inspection found no deficiencies. The incidents involved resident altercations and staff exposure, with appropriate notifications and follow-up actions taken, including medical evaluation and law enforcement involvement.

The inspection was an unannounced case management follow-up visit to investigate a self-reported incident involving resident altercation reported on 08/04/2022.

The report found no injuries resulting from the incident and no deficiencies were cited during the inspection. The facility had taken steps to address the situation including arranging a 1-on-1 companion for the resident involved and the resident has since moved.

The inspection was conducted as a case management follow-up regarding a self-reported incident involving a resident that occurred on April 14, 2022.

No injuries were found to the resident involved in the incident, and no deficiencies were cited during the inspection. The facility reported the incident to the Ombudsman and local police conducted an investigation. The staff member involved is not allowed back at the facility.

The visit was triggered by a complaint related to an incident where a staff member was rushing a resident with dementia, causing the resident to scream for help. The staff member refused interviews and is not associated with the facility or agency.

The visit was an unannounced case management incident to obtain additional information regarding two SOC 341 forms submitted by the facility on 4/25/2022 and 4/26/2022.

The Licensing Program Analyst interviewed staff, acquired more information, toured the facility, and found no deficiencies during the visit.

The inspection was an unannounced visit regarding an SOC 341 report submitted about an incident of an assault (slap) between two residents that occurred on 2022-03-08 at 6:15pm.

The facility reported the incident where resident R1 slapped resident R2, with no visible injuries noted on R2. Both residents' POA and PCP were contacted, and a medication review was requested for R1. The facility has had only one other similar incident in October 2021. Staff are monitoring both residents and keeping them separated during dining.

The visit was complaint-related due to an assault incident reported via SOC 341. The incident was substantiated with no injuries to the victim resident. Follow-up PCP appointments were conducted for both residents with no changes noted.

An unannounced Case Management visit was conducted regarding an incident and SOC 341 report submitted by the facility about an incident between two residents on 2022-03-09.

The incident involved two residents with one resident rubbing the other's neck and subsequent agitation. Staff intervened, and medical follow-up was ordered. The facility is managing the situation by keeping the residents apart. No deficiencies were cited during the visit.

The visit was complaint-related due to an incident reported by the facility. The incident was investigated and no deficiencies were found.

An unannounced Annual Required – 1 year Infection Control inspection was conducted to evaluate compliance with regulations and infection control measures.

The facility was found to be clean, well-maintained, and compliant with infection control and safety regulations. No deficiencies were cited during this inspection. The facility has adequate supplies, proper storage of medications and toxins, and staff have received required training and vaccinations.

The purpose of the informal office meeting was to discuss ongoing concerns that have been identified with the operation of this facility.

Staffing concerns were discussed, including recent hiring efforts and use of agency staff to supplement shifts. No deficiencies were cited during the visit.

The inspection was conducted as a complaint investigation regarding allegations of neglect/lack of supervision resulting in resident fall and injury, and insufficient staffing to meet residents' needs.

The allegation of insufficient staffing to meet residents' needs was substantiated, with findings showing the facility had only 4 caregivers for 39 residents, some requiring two-person assistance, posing an immediate risk. The allegation of neglect/lack of supervision resulting in resident fall and injury was unsubstantiated due to lack of sufficient evidence. No deficiencies were cited for the fall allegation, but a Type A deficiency was cited for insufficient staffing.

The complaint investigation was triggered by allegations of neglect/lack of supervision resulting in resident fall and injury, and insufficient staffing to meet residents' needs. The insufficient staffing allegation was substantiated, while the neglect/fall allegation was unsubstantiated.

The inspection was conducted as a complaint investigation regarding an allegation that the facility failed to take appropriate action regarding a scabies outbreak.

The investigation found that although there were residents and staff with rashes and some diagnosed with scabies, the Department was unable to prove or disprove that a scabies outbreak occurred in April. The allegation was determined to be unsubstantiated and no deficiencies were cited.

The complaint allegation was that the facility failed to take appropriate action regarding a scabies outbreak. The investigation was unsubstantiated, meaning there was not enough evidence to prove the alleged violation did or did not occur.

The visit was an unannounced case management incident to obtain additional information regarding SOC 341 submissions by residents on 6/9/2021, 6/23/2021, and 6/30/2021, and to address the issue of the facility not having a qualified administrator.

The facility was found to be in non-compliance due to not having a qualified administrator as required by Title 22 Regulations #87405(a). No deficiencies were cited during the visit.

An unannounced Annual Required – 1 year Infection Control inspection was conducted to evaluate compliance with regulations and infection control measures.

The facility was found to be clean, well-maintained, and compliant with infection control requirements including PPE availability, temperature checks, and approved mitigation plans. Some documents were requested to be updated by 5/31/2020. No deficiencies with severity labels were noted.

The inspection was an unannounced tele-visit conducted in regards to a case closure notice dated 11/3/2020 and included a follow-up check on the mitigation plan for the facility.

The Licensing Program Analyst verified that the individual I1 is not present, employed, or residing at the facility and advised the licensee to disassociate the individual from their roster and submit an updated LIC 500. Verification of removal was complete and no citations were issued during the visit.

report_4_496830756_inx3_2021-09-30.pdf