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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 09/07/2023
Date Signed: 09/07/2023 11:46:50 AM


Document Has Been Signed on 09/07/2023 11:46 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: 328DATE:
09/07/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Terence Tumbale, AdministratorTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced Health & Safety case management inspection and met with Terence Tumbale, Administrator. The purpose of this case management is to conduct a walk through of the newly renovated area of the 2nd floor consisting of Assisted Living & Memory Care units. There are 328 residents in the building.

LPA observed 24 rooms have been remodeled, 2 dining/activity rooms at each end of the second floor, 1 large activity room, a director’s office, medication room, a relaxation room, clean & soiled linen closets, and storage rooms. LPA toured 6 rooms and observed water temperatures in resident’s rooms not within Title 22 regulations. LPA is requesting facility submit a 7-day log of water temperatures in tested rooms, so water temperature is within regulations prior to residents moving in.

LPA has again requested an LIC200 be submitted to the department so that the department may initiate a new STD850 form be completed by the fire marshal to update the fire clearance on file prior to residents moving in.

The Department will receive an LIC200 by COB 9/8/2023.

Failure to submit may result in citation or civil penalties.

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: 09/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/07/2023
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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