Muirfield A Home for the Elderly

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Required - 1 Year

On 11/21/25 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Muirfield home for the elderly for the purpose of conducting a required 1 year annual inspection. LPA met with staff, Marilyn Carpio and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA measured the water temperature, temperature measured at 130 degrees F which does not meet the 105-120 degree Fahrenheit regulation. LPA observed the facility had an older thermometer that may not be reading the temperature accurately. LPA advised to obtain a new thermometer and turn down hot water. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Nov 21, 2025

The state marks this report as 3 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: POC

On 10/7/25 at 11:30am Licensing Program Analysts (LPAs) Kevin Gould and Noel Wolf-Petersen conducted an unannounced Plan of Correction (POC) inspection to ensure previously issued citation has been corrected and all POC documents completed. LPAs met with staff member who informed LPAs that administrator is currently out of the country (LPA Gould was notified in advance). the staff member present attested to completing training for food services but could not locate the documentation in administrative files and Administrator was unavailable via phone call. LPA spoke to designated substitute who also attested to completed training and said they would be able to send documentation of training to LPA today. No deficiencies noted or cited during today's inspection,the state’s words, verbatim · CDSS document, Oct 7, 2025

Allegation investigated: Staff hit resident. Staff did not provide medical attention to resident in a timely manner.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Muirfield A Home for the Elderly RCFE on 9/24/25 at 1:00pm to conclude the investigation of the above allegations and to deliver the findings. LPA Gould met with administrator, Marilyn Carpio and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould conducted interviews with two resident and one former resident. All residents interviewed denied being hit or abused by any staff member. Additionally, LPA could obtain no corroborating evidence that R1 did not receive medical attention in a timely manner. No staff member interviewed identified any delay in care or treatment for R1. LPA had received incident report for reported hospital visit to address health concerns for R1. Report Continued on LIC 9099-C Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 27-AS-20250821091850

Allegation investigated: Staff engaged in inappropriate interactions with residents in care

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Muirefield A Home For the Elderly RCFE on 9/24/25 at 1:00pm to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Marilyn Carpio and together discussed the investigation details. Based on the interviews conducted during the investigation process and statements obtained during the investigation process, LPA Gould was unable to corroborate the allegations. LPA Gould conducted several collateral inspections at current and previous placements for R1. No staff member has observed an individual visiting R1 or observed R1 in a romantic relationship with a caregiver from the facility at their current or former placement. Staff members interviewed denied the allegations. LPA conducted interview with R1's authorized representative and no other corroborating information was obtained. Report Continued on LIC 9099-C Unsubstantiated LPA conducted a collateral interview with R1 who does believe a relationship existed but was unable to provide any corroborating evidence and some information provided such as visitations was denied by staff at R1's current placement and former skilled nursing facility. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of personal rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Sep 24, 2025 · control 27-AS-20250903154616

Allegation investigated: Staff do not serve residents food of good quality

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Muirfield home for the elderly at 9:30am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Marilyn Carpio and together discussed the investigation details. Based on the LPA observations during the investigation process, the allegations are substantiated. LPA observed several expired food items in the fridge and multiple items stored without proper dating. LPA observed spaghetti with meat sauce that per staff member was prepared the prior evening to be served for lunch. LPA observed the pan was at room temperature and did not meet food storage requirements. LPA observed staff discard the food at LPAs request. LPA explained the storing of food could promote bacterial growth and posed a danger if consumed by residents. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of food services is substantiated. Report continued on LIC 9099-C. Substantiated The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 27-AS-20250801124152

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(23) · Plan of correction due date: Sep 5, 2025

General Food Service: All readily perishable foods or beverages capable of supporting rapid and progressive growth of micro-organisms which can cause food infections or food intoxications shall be stored in covered containers at appropriate temperatures. This requirement was not met as evidenced by LPA observations of food being stored without appropriate dates and spaghetti to be served for lunch stored at room temperature which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee has agreed to obtain training from an outside or online organization regarding food preparation and storage. facility will provide documentation of training for all staff by the POC due date.

Allegation investigated: Staff serving residents expired food.

Licensing Program Analysts (LPA) Kevin Gould made an unannounced inspection to the Muirfield home for the elderly at 9:30am to conclude the investigation of the above allegation and to deliver the findings. LPA Gould met with staff, Marilyn Carpio and together discussed the investigation details. Based on the LPA observations during the investigation process, the allegations are substantiated. LPA observed several expired food items in the fridge and multiple items stored without proper dating. LPA observed spaghetti with meat sauce that per staff member was prepared the prior evening to be served for lunch. LPA observed the pan was at room temperature and did not meet food storage requirements. LPA observed staff discard the food at LPAs request. LPA explained the storing of food could promote bacterial growth and posed a danger if consumed by residents. The Department has determined, based on the preponderance of the evidence obtained during this investigation, that the allegation of food services is substantiated. Report continued on LIC 9099-C. Substantiated The following deficiency is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the home. Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of medications are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies is cited per California Code of Regulations, TITLE 22. Exit interview was conducted with facility staff. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Aug 27, 2025 · control 27-AS-20250821091850

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87555(b)(8) · Plan of correction due date: Sep 5, 2025

General Food Service: All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained. This requirement was not met as evidenced by LPA observations of expired food items and food not being stored correctly to prevent contamination or bacterial growth which poses a potential health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Aug 27, 2025

Plan of correction: Licensee has agreed to obtain training from an outside or online organization regarding food preparation and storage. facility will provide documentation of training for all staff by the POC due date.

The state marks this report as 6 pages; the online copy we transcribed has 5. You can request the full file from the county licensing office.

Type of visit: Required - 1 Year

On 12/11/24 at 9:00am Licensing Program Analyst (LPA) Kevin Gould arrived at Muirfield A Home for the Elderly for the purpose of conducting a required 1 year annual inspection. LPA met with licensee, Marilyn Carpio and together conducted a tour of the home. LPA and Administrator evaluated the physical plant to ensure the health and safety of the residents in care. Areas inspected are including but not limited to the kitchen, resident bedrooms; resident bathrooms, living and dining room and outdoor areas. LPA observed the facility to be free of odor, clean and in good repair. LPA observed that all rooms are equipped with the required furniture and sufficient lighting throughout the facility. LPA observed the facility is still pre-pouring medications daily and LPA discussed the updated 2021 medications guide which discontinued the practice. LPA measured the water temperature, temperature measured at 130 degrees F and LPA observed the licensee turn down the hot water heater and on a second testing recorded a temperature of 118 degrees which meets the 105-120 degree Fahrenheit regulation. LPA observed sufficient seven day non-perishable and two day perishable food supplies. Fire extinguishers and smoke detectors are current and in compliance with fire safety. LPA notes the facility had the required carbon monoxide detectors. First aid kit was checked and is complete. LPA observed centrally stored medications secure from residents. LPA Requested the following documents for facility file: LIC 308 Designation of Facility Responsibility, LIC 500 personnel report, LIC 9020 client roster and current administrator certificate. Per California Code of Regulations, Title 22 there were no deficiencies cited during today's inspection. An exit interview was conducted, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Dec 11, 2024

Allegation investigated: Personal Rights: Staff hit resident in care.

Licensing Program Analyst (LPA) Kevin Gould conducted an unannounced complaint inspection at Muirfield A Home for the Elderly on 2/23/24 at 1:30pm to inform the licensee of complaint allegation mentioned above. During this investigation LPA Gould interviewed S1, R1, R2 and R3 (See confidential name list LIC-811 dated 2/23/24). Based on the interviews and statements obtained during the investigation process, the allegations cannot be substantiated because All residents interviewed denied the allegations including the identified alleged victim. All statements obtained indicate that staff were attempting to wake resident who was making a disturbance in their sleep. Resident states she now understand staff were attempting to wake her and is what they also informed the police when they responded to the home. Report Continued on LIC 9099-C Unsubstantiated Although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. The Department has determined that the allegations of Personal Rights are unsubstantiated but if any additional information is received this complaint can be amended and the finding can be changed. There are no deficiencies noted or cited per California Code Regulation, TITLE 22 Exit interview was conducted with the facility administrator. Appeal Rights were issued, and a copy of this report was left at the facility.the state’s words, verbatim · CDSS document, Feb 23, 2024 · control 27-AS-20240221133222

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Ruth Wallace conducted unannounced required annual inspection visit. LPA met with House Manager and explained purpose of visit. Administrator certificate expires on 11/8/2024. The facility is licensed to served six non-ambulatory residents. Hospice waiver approved for four residents. There are currently six residents and no residents are on hospice at this time. LPA and house manager inspected the physical plant including but not limited to the common area, kitchen, dining area, resident bedrooms, resident bathrooms, laundry area, and outside courtyards of the facility to ensure compliance with Title 22 regulations. LPA observed the facility is clean and in good repair. LPA observed sufficient furniture and lighting throughout the facility. Hot water temperature was observed to be 114.5 degrees Fahrenheit. Facility thermostat observed at 75 degrees Fahrenheit. Food supply is adequate for two day perishable and seven day nonperishable. LPA observed knives and toxins to be locked away and inaccessible to clients. Smoke and carbon detectors were in good repair. Fire extinguisher was last inspected on 11/17/2022 and first aid kit was current. LPA checked medication storage and found medication to be locked away and inaccessible to residents. The facility mitigation plan was submitted to community care licensing and it was approved on 2/16/2021. LPA reviewed and compared resident medication vs. resident medication logs. LPA reviewed four resident and four staff files, including criminal record clearances. All staff are fingerprint cleared and associated to the facility. First aid kit was checked and is complete. LPA requested the following updated documents to be submitted via email to community care licensing by 12/4/2023: LIC 308 - Designation of Administrator, copy of deed, copy of administrator's certificate, and liability insurance. ruth.wallace@dss.ca.gov Per the California Code of Regulations, Title 22 no deficiencies were observed or cited. Exit interview held with house manager. A report and LIC 811 (Confidential Names) was left at the facility.the state’s words, verbatim · CDSS document, Nov 16, 2023