210102761-6-16-2021-21-AS-HDBI-C543EF-20210719181101

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102761
Report Date: 06/16/2021
Date Signed: 06/16/2021 09:46:23 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210326154450

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: 251	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Executive Director, Wesley Bard		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Residents are not treated with dignity and respect
Licensee failed to ensure facility is safe sanitary and in good repair

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi conducted a complaint investigation and met with Executive Director, Wesley Bard for the purpose of delivering complaint findings. LPA initiated the investigation on March 30, 2021 and during the course of the investigation, LPA Sarangi interviewed staff, residents and various outside parties, including but not limited to responsible parties, witnesses and conducted virtual tour of the facility (May 10, 2021). Various documents were gathered and reviewed including facility records and a Special Incident Report (SIR) dating back to April 08, 2018 regarding an unwitnessed fall in the 1st floor common area restroom.

Complaint alleges that residents are not being treated with dignity and respect. Based on multiple interviews with staff, residents and the complainant, LPA learned that there were no other individuals that were able to corroborate the concern that residents and staff are berated and yelled at by the Executive Director. Personnel Records and disciplinary records were reviewed that revealed that although the Executive Director is called upon to discipline staff as needed, they do not infringe on personal rights or employee rights. As it relates to this allegation, there is insufficient information to prove or disprove the allegation. (Report continued on LIC 9099C)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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-20210326154450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/16/2021

NARRATIVE

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Complaint alleges that the licensee failed to ensure facility is safe sanitary and in good repair. LPA reviewed records, interviewed residents and staff and conducted a facility tour of the 1^st floor on May 10, 2021 at approximately 02:00 PM. LPA observed the facility to be clean, safe, sanitary and in good repair on May 10, 2021. LPA reviewed previous Special Incident Reports regarding the complainant’s allegation and found that there was an incident that occurred on April 08, 2018 and reported to California Department of Social Services on April 11, 2018. During this review, it was noted that a resident slipped on a wet floor and that the “Caution-Wet Sign” was not displayed. Executive Director suspended the staff member and retrained the staff member on mopping procedures. LPA made two attempts to contact the resident that slipped but was unsuccessful. Based on interviews and record reviews LPA was able to verify hat the prior incident had been addressed and appropriately reported but was unable to identify that any additional incidents of this nature have occurred since. As it relates to this allegation, there is insufficient information to prove or disprove the allegation.

Based on the interviews that were conducted and the documents/evidence reviewed, the allegations of, residents not being treated with dignity and respect and licensee failing to ensure facility is safe, sanitary and in good repair is Unsubstantiated meaning that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore, the allegations are Unsubstantiated.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/26/2021 and conducted by Evaluator Farhaan Sarangi

COMPLAINT CONTROL NUMBER: 21-AS-20210326154450

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: 251	DATE:	06/16/2021
		UNANNOUNCED	TIME BEGAN:	08:26 AM
MET WITH:	Executive Director, Wesley Bard		TIME COMPLETED:	09:30 AM

ALLEGATION(S):

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Resident garage was blocked by van preventing residents from being able to exit with their cars

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA), Farhaan Sarangi conducted a complaint investigation and met with Executive Director, Wesley Bard for the purpose of delivering complaint findings. LPA initiated the investigation on March 30, 2021 and during the course of the investigation, LPA Sarangi reviewed various documents and pieces of evidence, interviewed staff, residents and various outside parties, including but not limited to responsible parties, witnesses and conducted virtual tour of the facility (May 10, 2021).

Complaint alleges that the Resident garage was blocked by van preventing residents from being able to exit with their cars. Based on interviews with residents, staff and various outside parties and evidence gathered LPA observed a picture depicting a van blocking the entrance and exit of the resident garage was reviewed. In addition, interviews with Marin County Department of Public Health indicate that this was not part of the guidance during COVID-19, and instead the facility created this blockage thus preventing residents from entering and leaving the facility. LPA interviewed the Executive Director and CEO who confirmed this was created due to COVID-19. Also, during this interview, the Executive Director stated that it didn’t prevent any residents from leaving or entering, and instead residents had to check in with the facility when they left or entered into the facility. (Report continued on LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

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

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 21-AS-20210326154450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 06/16/2021

NARRATIVE

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Based upon statements made, the picture reviewed and analyzed, the preponderance of evidence standard has been met regarding the resident garage being blocked by van preventing residents from being able to exit with their cars. Therefore, the above allegation is found to be SUBSTANTIATED. The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal of rights provided.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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Citations on this Visit Report are Under Appeal!

Control Number 21-AS-20210326154450

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/16/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Under Appeal Type B 06/16/2021 Section Cited CCR 87468.1(a)(6)	1 2 3 4 5 6 7	-Personal Rights of Residents in All facilities. To leave or depart the facility at any time and to not be locked into any room, building, or on facility premises by day or night. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Facility agrees to submit a plan of how the facility will not violate residents’ personal rights with regards to leaving the facility along with a plan regarding retraining staff on Personal Rights as well as how this will be executed moving forward.
	8 9 10 11 12 13 14	Based on a review of photographic evidence, it was revealed that a facility van was blocking the entrance and exit which could prevent residents from leaving during an emergency. In addition, the County of Marin did not issue this guidance and the facility took it upon itself to create their own guidance by blocking the entrance and exit with a facility van. This was corroborated during an interview with the complainant, a witness and the facilities Executive Director.	8 9 10 11 12 13 14	Facility to submit the updated policy and plan for training to CCL by June 24, 2021. Proof of training including topics covered and sign in sheet to be submitted to CCL by June 24, 2021.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Hope DeBenedetti	TELEPHONE: (707) 588-5029
LICENSING EVALUATOR NAME: Farhaan Sarangi	TELEPHONE: 707-588-5034
LICENSING EVALUATOR SIGNATURE:	DATE: 06/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/16/2021

LIC9099 (FAS) - (06/04)

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