210102761-6-11-2021-21-AS-FSAI-C3VS8F-20210611133905

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 06/11/2021
Date Signed: 06/11/2021 04:35:38 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME:	TAMALPAIS		FACILITY NUMBER:	210102761
ADMINISTRATOR:	GOERZEN, ROB		FACILITY TYPE:	741
ADDRESS:	501 VIA CASITAS		TELEPHONE:	(415) 461-2300
CITY:	GREENBRAE	STATE: CA	ZIP CODE:	94904
CAPACITY:	341	CENSUS: 250	DATE:	06/11/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:08 AM
MET WITH:	Executive Director, Wesley Bard		TIME COMPLETED:	11:50 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	License Program Analysts (LPAs) Farhaan Sarangi and Erik Gonzalez-Campos arrived unannounced to conduct an Required – 1 year visit of the facility. LPAs were welcomed by front desk who contacted Executive Director, Wesley Bard for the visit. Facility is in the process of changing Administrators and have submitted documentation to Community Care Licensing. There is a total of 20 assisted living residents and 230 independent living residents. One resident in Assisted Living is on Hospice. The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on the second floor. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPAs toured the assisted living part of the facility on June 11, 2021 at 09:30 AM with Executive Director, Wesley Bard, Ashley McCargar (RN) and Terrance Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on May 2021. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured at an acceptable range and within Title 22 acceptable regulation of 105 to 120 degrees in the downstairs common area across the study hall, 1 assisted living and 1 independent living resident’s bathrooms while touring facility on June 11, 2021 at 10:30 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area with Executive Director and learned that there are provisions made for individuals/residents with special dietary needs. (Report continued on LIC 809C)

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TAMALPAIS	FACILITY NUMBER: 210102761
	VISIT DATE: 06/11/2021

NARRATIVE

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Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There is supply of cleaners, hygiene products and paper products available for residents.

LPAs advised facility to contact County Public Health and Community Care Licensing immediately if symptoms or COVID-19 + in the facility. Disaster Drills were conducted June 2021. LPAs reviewed the Mitigation Plan with the facility. Facility has already been N95 Fit tested. Emergency Disaster plan was discussed with the Executive Director. Personal Protective Equipment is sufficient.

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facilities Executive Director, Wesley Bard.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/11/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2021

LIC809 (FAS) - (06/04)

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