496830756-6-19-2026-21-AS-BMOS-DVCMBV-20260624092835

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 496830756
Report Date: 06/19/2026
Date Signed: 06/19/2026 03:33:39 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/14/2026 and conducted by Evaluator Star Stevenson

COMPLAINT CONTROL NUMBER: 21-AS-20260414084720

FACILITY NAME:	MUIRWOODS MEMORY CARE		FACILITY NUMBER:	496830756
ADMINISTRATOR:	GRANT HAYWOOD		FACILITY TYPE:	740
ADDRESS:	750 NORTH MCDOWELL BLVD		TELEPHONE:	(707) 775-4330
CITY:	PETALUMA	STATE: CA	ZIP CODE:	94954
CAPACITY:	80	CENSUS: 42	DATE:	06/19/2026
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Tolu Faaita-Business Office Manager		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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Staff did not ensure residents care needs were met

INVESTIGATION FINDINGS:

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On 06/19/2026 Licensing Program Analyst (LPA) arrived unannounced to deliver complaint findings on the above complaint allegation. LPA met with Tolu Faaita-Business Office Manager who has Designation of Faciltiy Responsibilty (RP)

On 04/14/2026 Community Care Licensing (CCL) received a complaint from Reporting party that on 04/10/2026, “care staff never showed up for their shift and resident (R1) was neglected all day” In addition, the reporting party stated that, “a few other residents that, day were also neglected”

On 04/20/2026 LPA conducted an unannounced visit to Muirwoods Memory care, made observations, conducted interviews and obtained documents.

The investigation revealed that (1) staff scheduled for the PM shift on 4/10/2026 did not show up as scheduled. The facility contacted a staff member to cover the shift who arrived approximately two hours later.
Continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

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-20260414084720

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: MUIRWOODS MEMORY CARE	FACILITY NUMBER: 496830756
	VISIT DATE: 06/19/2026

NARRATIVE

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Continued from LIC9099-C

LPA interviewed four (4) witness visitors who raised no concerns for lack of staffing leading to care neglect.

On 06/19/2026 LPA conducted subsequent interviews with four (4) staff which revealed no supporting information that residents’ care needs are not being met.

LPA obtain emails related to staffing and care concerns, Care Notes for R1 through April 11th, 2026, as well as a staffing schedule and adjustments to staffing made on April 10th, 2026.

LPA also obtain a Physicians Report and Admissions Order (LIC602) for R1 dated 01/12/2025, a Service Plan for R1 dated 01/08/2026, and Assisted Living Resident & Service Agreement dated 06/12/2024

Finally, LPA obtained copies of Petaluma Police Incident/Investigation report dated 04/14/2026 which indicated physical signs of neglect or elder abuse to be unfounded.

Due to conflicting information obtained as to whether R1’s care needs were met or not met in the afternoon and early evening of April 10th, 2026, the allegation of “Staff did not ensure residents care needs were met” is unsubstantiated.

An allegation of Unsubstantiated means although the allegation may have occurred or may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Star Stevenson
LICENSING EVALUATOR SIGNATURE:	DATE: 06/19/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2026

LIC9099 (FAS) - (06/04)

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