Inspection Reports for MuirWoods Memory Care
750 N McDowell Blvd, Petaluma, CA 94954, CA, 94954
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally maintaining a clean and safe environment and following required protocols. The most recent report from September 9, 2025, was perfect with no deficiencies noted during an unannounced case management visit. Some earlier inspections cited deficiencies related to unlocked storage of toxic chemicals and missing window screens in April 2025, as well as substantiated issues with understaffing affecting incontinence care and failure to seek medical attention for a resident’s injury in early 2025. Other complaints about medication administration and resident care needs were mostly unsubstantiated, and the facility showed improvement with no deficiencies in subsequent inspections. Overall, the facility appears to have addressed prior concerns, with recent reports indicating compliance and no new citations.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
1.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
68% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
61% occupied
Based on a September 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Census: 49
Capacity: 80
Deficiencies: 0
Date: Sep 9, 2025
Visit Reason
The visit was an unannounced case management inspection conducted to review the facility's compliance and to follow up on the administrator change process.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Heather Montgomery | Interim Executive Director | Met during the inspection and discussed administrator change. |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management visit. |
Inspection Report
Census: 49
Capacity: 80
Deficiencies: 0
Date: Sep 2, 2025
Visit Reason
Unannounced Health and Safety inspection conducted as part of Case Management - Health Checks.
Findings
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.
Report Facts
Staff observed: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Medina | Administrator | Met during inspection and mentioned in the report. |
| Lupe Villa-Guerrero | Director of Health Services | Met during inspection and mentioned in the report. |
Inspection Report
Follow-Up
Census: 47
Capacity: 80
Deficiencies: 0
Date: Jul 3, 2025
Visit Reason
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.
Findings
The Licensing Program Analyst conducted interviews and observations during the visit and found no citations or deficiencies during this follow-up inspection.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carolina Rodas-Reyes | Head Medication Technician | Met with Licensing Program Analyst during the inspection as designee authorized to sign for the visit. |
Inspection Report
Annual Inspection
Census: 48
Capacity: 80
Deficiencies: 2
Date: Apr 18, 2025
Visit Reason
The inspection was an unannounced Annual Required - 1 Year inspection conducted to evaluate compliance with licensing requirements at the memory care facility.
Findings
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.
Deficiencies (2)
Janitorial Closet on Side 1 left ajar/open containing toxic cleaning chemicals and storage closet 1 unlocked containing electrical panel accessible to dementia residents.
26 missing window screens between the inside and exterior of the facility, along with additional damaged screens.
Report Facts
Residents receiving Hospice services: 13
Number of apartments: 40
Hot water temperature: 108.6
Hot water temperature: 115
Number of resident and staff records reviewed: 12
Number of resident medications reviewed: 2
Number of locked medication carts: 2
Disaster drill frequency: 4
Plan of Correction due date for toxic chemical storage deficiency: Apr 21, 2025
Plan of Correction due date for window screen deficiency: May 2, 2025
Deadline for document updates requested by LPA: May 7, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karina Medina | Administrator | Met with Licensing Program Analyst during inspection; named in findings related to facility tour and observations |
| Lupe Villa-Guerrero | Director of Health Services | Accompanied Licensing Program Analyst during facility tour |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and signed the report |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
| Regional Director of Health & Wellness | Interviewed regarding window screen repairs |
Inspection Report
Complaint Investigation
Census: 50
Capacity: 80
Deficiencies: 0
Date: Mar 20, 2025
Visit Reason
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.
Complaint Details
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.
Findings
The Licensing Program Analyst met with the Director of Health Services, obtained documents, and no citations were given during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analyst during the investigation of the alleged sexual assault. |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management visit regarding the alleged sexual assault. |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on the report. |
Inspection Report
Census: 47
Capacity: 80
Deficiencies: 0
Date: Jan 29, 2025
Visit Reason
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.
Complaint Details
Complaint 21-AS-20240719150606 findings were delivered during the meeting.
Findings
The administrator informed there were no concerns regarding the facility's financial solvency. The meeting also covered the findings of the referenced complaint.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met during the inspection and provided information regarding financial solvency. |
| Bethany Moellers | Licensing Program Manager | Present at the informal meeting. |
| Shannan Hansen | Licensing Program Analyst | Present at the informal meeting. |
| Courtney Lane | Regional Director of Operations | Participated via Teams in the meeting. |
| Denise Munoz | Corporate Director of Administration | Participated via Teams in the meeting. |
| Kimberly Kooy | Reg. DHW | Participated via Teams in the meeting. |
Inspection Report
Complaint Investigation
Census: 47
Capacity: 80
Deficiencies: 1
Date: Jan 29, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Facility personnel were not sufficient in numbers and competent to meet resident needs, specifically regarding incontinence care and double briefing, posing an immediate health and safety risk.
Report Facts
Facility capacity: 80
Census: 47
Deficiency due date: Jan 30, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with during inspection and named in findings |
| Bethany Moellers | Licensing Program Manager | Delivered findings and signed report |
| Shannan Hansen | Licensing Program Analyst | Conducted investigation and signed report |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 80
Deficiencies: 1
Date: Jan 7, 2025
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure residents are regularly observed for changes and to seek medical attention after observing R1's injury.
Report Facts
Capacity: 80
Census: 44
Plan of Correction Due Date: Jan 8, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Executive Director | Met with Licensing Program Analyst during inspection and named in findings |
| Marisol Cuadra | Licensing Program Analyst | Conducted the inspection and cited deficiencies |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 44
Capacity: 80
Deficiencies: 0
Date: Jan 7, 2025
Visit Reason
The inspection was an unannounced complaint investigation triggered by an allegation that a resident sustained unexplained bruising while in care.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 80
Resident census: 44
Complaint control number: 21-AS-20241002083624
Case number: Police case #24-3919
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Marisol Cuadra | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Camille Brown | Executive Director | Facility administrator met during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 45
Capacity: 80
Deficiencies: 0
Date: Aug 20, 2024
Visit Reason
The inspection was an unannounced Health and Safety inspection conducted as part of Case Management - Health Checks.
Findings
The facility was found to be clean, at a comfortable temperature, with adequate staffing and sufficient food. No deficiencies were cited during the visit.
Report Facts
Staff observed: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the Health and Safety inspection |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Annual Inspection
Census: 45
Capacity: 80
Deficiencies: 1
Date: Apr 12, 2024
Visit Reason
An unannounced Annual Required - 1 Year inspection was conducted to evaluate compliance with regulations at the memory care facility.
Findings
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.
Deficiencies (1)
In 7 out of 9 bedrooms inspected, items such as mouthwash with alcohol, nail polish, spray cans of air freshener, sewing needles, creams, ointments, shampoo, and conditioners were stored in rooms not locked and accessible to residents, posing an immediate health, safety, or personal rights risk.
Report Facts
Residents on Hospice: 10
Resident bedrooms inspected: 9
Resident records reviewed: 5
Staff records reviewed: 5
Resident medications reviewed: 3
Deficiency POC due date: Apr 15, 2024
Staff training POC due date: Apr 19, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lisa Lomeli | Director of Sales | Met with LPA during inspection as Administrator was unavailable |
| Lupe Villa-Guerrero | Director of Health Services | Accompanied LPA during facility tour and involved in removal of hazardous items |
| Kyle Manford | Director of Environmental Services | Accompanied LPA during facility tour and provided information on disaster preparedness |
| Camille Brown | Administrator | Facility Administrator with certificate expiring 7/24/2024 |
| Bethany Moellers | Licensing Program Manager | Supervisor overseeing licensing evaluation |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 52
Capacity: 80
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
Unannounced complaint investigation visit triggered by allegations that staff did not prevent outbreaks of scabies and COVID-19 at the facility.
Complaint Details
Complaint was unsubstantiated based on lack of preponderance of evidence to prove or disprove the allegations regarding scabies and COVID-19 outbreaks.
Findings
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.
Report Facts
Complaint Control Number: 21
Number of site visits: 3
Resident files reviewed: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| David Leibert | Evaluator / Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Camille Brown | Administrator | Facility administrator named in report header |
Inspection Report
Complaint Investigation
Census: 55
Capacity: 80
Deficiencies: 0
Date: Feb 1, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Staff count: 6
Staff count: 23
Housekeepers: 3
Training records reviewed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with Licensing Program Analyst during complaint investigation |
| Shannan Hansen | Licensing Program Analyst | Conducted complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 80
Deficiencies: 0
Date: Nov 13, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 80
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with Licensing Program Analyst during investigation |
| Lupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analyst and provided information regarding resident care |
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 54
Capacity: 80
Deficiencies: 0
Date: Nov 2, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Complaint Control Number: 21
Complaint Control Number Suffix: 20231016084025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Shannan Hansen | Licensing Program Analyst | Conducted the complaint investigation |
| Camille Brown | Administrator | Met with Licensing Program Analyst during investigation |
| Bethany Moellers | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Census: 80
Capacity: 80
Deficiencies: 0
Date: Sep 12, 2023
Visit Reason
This was an unannounced Case Management Visit to amend a previously issued report dated 07/24/2023 due to an incorrect date reference.
Findings
The report was amended and signed on 09/12/2023. No citations or deficiencies were issued during this visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analysts during the Case Management Visit. |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 80
Deficiencies: 1
Date: Jul 24, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
87705 Care of Persons with Dementia - Facility failed to conduct annual medical assessment and reappraisal including reassessment of dementia care needs, resulting in an immediate risk to health and safety.
Report Facts
Facility capacity: 80
Census: 51
Plan of Correction due date: Jul 25, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with Licensing Program Analyst during investigation and named in findings |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation and delivered findings |
| Hope DeBenedetti | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 51
Capacity: 80
Deficiencies: 0
Date: Jul 24, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 80
Census: 51
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with Licensing Program Analyst during investigation |
| Victoria Bertozzi | Licensing Program Analyst | Conducted the complaint investigation |
| Hope DeBenedetti | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 47
Capacity: 80
Deficiencies: 0
Date: Apr 4, 2023
Visit Reason
An unannounced annual inspection was conducted as part of the case management annual continuation to evaluate compliance with licensing requirements.
Findings
No deficiencies were cited during the inspection. Staff records, administrator certification, medication records, and interviews were reviewed and found compliant.
Report Facts
Staff records reviewed: 5
Staff interviews conducted: 4
Client interviews conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met during inspection and mentioned in report |
| Shannan Hansen | License Program Analyst | Conducted the inspection |
Inspection Report
Annual Inspection
Census: 48
Capacity: 80
Deficiencies: 0
Date: Mar 30, 2023
Visit Reason
The inspection was an unannounced Annual Required - 1 Year inspection of the Muirwoods Memory Care Facility conducted by the License Program Analyst.
Findings
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.
Report Facts
Residents on Hospice: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Talu Faaita | Business Office Manager | Met with LPA during inspection and accompanied facility tour |
| Kyle Manford | Director of Environmental Services | Accompanied LPA during facility tour |
| Camille Brown | Administrator | Facility Administrator unavailable during inspection |
Inspection Report
Follow-Up
Census: 47
Capacity: 80
Deficiencies: 0
Date: Mar 14, 2023
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Incident monitoring duration: 48
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Administrator | Met with Licensing Program Analyst during inspection |
| Lupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Census: 54
Capacity: 80
Deficiencies: 0
Date: Oct 20, 2022
Visit Reason
The inspection was an unannounced case management visit to follow up on an anonymous complaint regarding laundry piling up outside of the laundry room.
Complaint Details
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.
Findings
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.
Report Facts
Capacity: 80
Census: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Interim Executive Director | Met with Licensing Program Analyst during inspection |
Inspection Report
Follow-Up
Census: 55
Capacity: 80
Deficiencies: 0
Date: Oct 5, 2022
Visit Reason
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.
Findings
The inspection found that residents involved in incidents were appropriately managed with hospitalizations and follow-ups. No deficiencies were cited during the inspection.
Report Facts
Incident reports followed up: 5
Incident dates: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection |
Inspection Report
Census: 50
Capacity: 80
Deficiencies: 0
Date: Aug 26, 2022
Visit Reason
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.
Findings
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.
Report Facts
Incident dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Camille Brown | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Follow-Up
Census: 48
Capacity: 80
Deficiencies: 0
Date: Aug 9, 2022
Visit Reason
The inspection was an unannounced case management follow-up visit to investigate a self-reported incident involving resident altercation reported on 08/04/2022.
Findings
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.
Report Facts
Incident report date: Aug 3, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Villa-Guerrero | Director of Health Services | Met during inspection and involved in follow-up on incident |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Brandee Rodriguez | Administrator | Facility administrator at time of inspection |
| Camille Brown | Interim Administrator | New Interim Administrator signed during inspection |
Inspection Report
Complaint Investigation
Census: 41
Capacity: 80
Deficiencies: 0
Date: May 4, 2022
Visit Reason
The inspection was conducted as a case management follow-up regarding a self-reported incident involving a resident that occurred on April 14, 2022.
Complaint Details
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analyst during inspection and provided information about the incident and investigation. |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced case management inspection. |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager. |
Inspection Report
Census: 44
Capacity: 80
Deficiencies: 0
Date: Apr 28, 2022
Visit Reason
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.
Findings
The Licensing Program Analyst interviewed staff, acquired more information, toured the facility, and found no deficiencies during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Kathleen Perry | Medication Technician | Met with during the case management visit. |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 80
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Report Facts
Incident date: Mar 8, 2022
Report submission date: Mar 10, 2022
Incident time: 1815
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Guadalupe Villia | Caregiver | Witnessed the assault incident between residents |
| Lupe Villa-Guerrero | Director of Health Services | Provided information about prior incident and resident monitoring |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced visit |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 80
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
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.
Complaint Details
The visit was complaint-related due to an incident reported by the facility. The incident was investigated and no deficiencies were found.
Findings
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.
Report Facts
Incident date: Mar 9, 2022
Report submission date: Mar 11, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Lupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analyst regarding the incident |
| Shannan Hansen | Licensing Program Analyst | Conducted the unannounced Case Management visit |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Annual Inspection
Census: 43
Capacity: 80
Deficiencies: 0
Date: Mar 16, 2022
Visit Reason
An unannounced Annual Required – 1 year Infection Control inspection was conducted to evaluate compliance with regulations and infection control measures.
Findings
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.
Report Facts
Residents on Hospice: 8
Hot water temperature range: 111.7-114.6
Fire extinguisher last charged date: Dec 7, 2021
Administrator Certificate Expiration: Jul 12, 2023
Documents requested for submission: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Karen Moore | Interim Executive Director | Met with Licensing Program Analyst during inspection |
| Tolu Faaita | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Lupe Villa-Guerrero | Director of Health Services | Met with Licensing Program Analyst during inspection |
| Brandee Rodriguez | Administrator | Administrator certificate reviewed during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Bethany Moellers | Licensing Program Manager | Named in report header |
Inspection Report
Census: 44
Capacity: 80
Deficiencies: 0
Date: Oct 12, 2021
Visit Reason
The purpose of the informal office meeting was to discuss ongoing concerns that have been identified with the operation of this facility.
Findings
Staffing concerns were discussed, including recent hiring efforts and use of agency staff to supplement shifts. No deficiencies were cited during the visit.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandee Rodriguez | Administrator | Named as Executive Director returning from leave |
| Courtney Hill | Regional Director of Operations of Northern CA | Present at the meeting and overseeing facility operations |
| Tracy Freudendahl | Interim Executive Director | Present at the meeting and overseeing facility operations |
| Kimberley Mota | Licensing Program Manager | Present at the meeting |
| Bethany Moellers | Licensing Program Manager | Present at the meeting |
| Shannan Hansen | Licensing Program Analyst | Present at the meeting |
| Carla Fernandez-Goes | Licensing Program Analyst | Present at the meeting |
Inspection Report
Complaint Investigation
Capacity: 80
Deficiencies: 1
Date: Sep 30, 2021
Visit Reason
The inspection was an unannounced Case Management visit following up on a self-reported medication error incident that occurred on 2021-09-16 involving resident R1.
Complaint Details
The visit was complaint-related, following up on a self-reported medication error incident. The resident did not suffer adverse effects. The deficiency was substantiated as an immediate health and safety risk.
Findings
A medication error was identified where resident R1 was not given the prescribed medication and was given another resident's medication instead. No adverse effects were reported. One deficiency was cited related to failure to assist residents with self-administered medications as required, posing an immediate health and safety risk.
Deficiencies (1)
The licensee failed to assist residents with self-administered medications as needed; resident R1 was not given medication as prescribed, posing an immediate health and safety risk.
Report Facts
Facility capacity: 80
Deficiency count: 1
Incident date: Sep 16, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Brandee Rodriguez | Administrator | Administrator was on leave during inspection |
| Tolu Faaita | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Shannan Hansen | Licensing Program Analyst | Conducted the inspection |
| Kimberley Mota | Licensing Program Manager | Supervisor and Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 39
Capacity: 80
Deficiencies: 1
Date: Aug 31, 2021
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Personnel Requirements - Facility personnel shall at all times be sufficient in numbers and competent to provide the services necessary to meet resident needs. Facility did not comply with this requirement for 39 residents, posing an immediate risk.
Report Facts
Residents with fall concerns: 32
Residents needing assistance: 9
Ambulatory residents: 15
Ambulatory with assistance: 15
Residents in wheelchair: 9
Current census: 39
Total capacity: 80
Caregivers on shift: 4
Caregivers on night shift: 2
Residents by care level: 4
Residents by care level: 11
Residents by care level: 10
Residents by care level: 9
Residents by care level: 5
Residents needing toileting assistance: 26
Residents needing meal assistance: 29
Residents needing total meal assistance: 6
Residents needing transfer assistance: 9
Residents needing diaper changes: 27
Residents on hospice: 5
Residents needing status checks 4 times per shift: 37
Residents needing status checks 8 times per shift: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Oversaw the complaint investigation |
| Tolu Faaita | Business Office Manager | Met with Licensing Program Analysts during investigation |
| Jamie E Gralund | Administrator | Facility administrator named in report |
| Brandee R. | Executive Director | Interviewed during investigation regarding staffing concerns |
Inspection Report
Complaint Investigation
Census: 40
Capacity: 80
Deficiencies: 0
Date: Aug 25, 2021
Visit Reason
The inspection was conducted as a complaint investigation regarding an allegation that the facility failed to take appropriate action regarding a scabies outbreak.
Complaint Details
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.
Findings
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.
Report Facts
Facility capacity: 80
Census: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the complaint investigation |
| Bethany Moellers | Licensing Program Manager | Named in the report as Licensing Program Manager |
| Brandee Rodriguez | Executive Director | Met with during the investigation |
Inspection Report
Census: 37
Capacity: 80
Deficiencies: 0
Date: Jul 7, 2021
Visit Reason
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.
Findings
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.
Report Facts
Date of administrator change: May 11, 2021
Deadline for proof of pending administrator certificate: Jul 14, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie E Gralund | Administrator | Named as facility administrator at time of report |
| Tolu Faaita | Business Office Manager | Met during the visit and involved in case management |
| Denise Munoz | Corporate Director | Contacted Department regarding administrator change |
Inspection Report
Annual Inspection
Census: 37
Capacity: 80
Deficiencies: 0
Date: May 17, 2021
Visit Reason
An unannounced Annual Required – 1 year Infection Control inspection was conducted to evaluate compliance with regulations and infection control measures.
Findings
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.
Report Facts
Capacity: 80
Census: 37
30-day medication supply: 30
Disaster drill date: 202104
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the inspection and authored the report |
| Tolu Faaita | Business Office Manager | Met with Licensing Program Analyst during inspection |
| Guadalupe Villa-Guerrerro | Staff member met during inspection | |
| Jamie E Gralund | Administrator | Facility administrator mentioned as new administrator |
| Bethany Moellers | Licensing Program Manager | Named as Licensing Program Manager |
Inspection Report
Census: 42
Capacity: 80
Deficiencies: 0
Date: Dec 7, 2020
Visit Reason
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.
Findings
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.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jamie Gralund | Executive Director | Met with during the tele-visit and provided information about the individual I1. |
| Carla Martinez | Licensing Program Manager | Named as Licensing Program Manager on the report. |
| Carla Fernandes-Goes | Licensing Program Analyst | Conducted the tele-visit inspection and verified the individual I1's status. |
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