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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 04/24/2023
Date Signed: 04/25/2023 10:49:52 AM


Document Has Been Signed on 04/25/2023 10:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405



FACILITY NAME:TAMALPAISFACILITY NUMBER:
210102761
ADMINISTRATOR:TUMBALE, TERENCEFACILITY TYPE:
741
ADDRESS:501 VIA CASITASTELEPHONE:
(415) 461-2300
CITY:GREENBRAESTATE: CAZIP CODE:
94904
CAPACITY:341CENSUS: 224DATE:
04/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Terence Tumbale, AdministratorTIME COMPLETED:
02:15 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a required annual inspection of the facility. LPA was welcomed by front desk. LPA met with Administrator Terence Tumbale for the visit. There is a total of 22 assisted living residents and 202 independent living residents. There are two residents currently 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 but currently due to construction have been temporarily moved. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing.

LPA toured the assisted living part of the facility on 4/24/2023 at 9:15 AM with administrator, Terence 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 3/7/2023 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current. Facility service director Stewart Dalie stated that boiler is outside of building and kitchen stove is gas. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 110.4 degrees F and 114.8 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 8 of 8 assisted living & independent living resident’s bathrooms while touring facility on 4/24/2023 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 on 4/24/2023 at 11:00 AM with administrator Terence and Director of Environmental Services Stewart Dalie and learned that there are provisions made for individuals/residents with special dietary needs.



Continue on LIC809-C
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TAMALPAIS
FACILITY NUMBER: 210102761
VISIT DATE: 04/24/2023
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Facility kitchen has a binder with resident’s names and their needs. 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 was a supply of cleaners, hygiene products and paper products available for residents. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing.

At 11:50 AM LPA initiated a file review of five resident files and five personnel files but was unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection.

No deficiencies cited during today’s inspection.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023
LIC809 (FAS) - (06/04)
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