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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210102761
Report Date: 10/09/2023
Date Signed: 10/09/2023 11:33:22 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/31/2023 and conducted by Evaluator Jennifer Walden
COMPLAINT CONTROL NUMBER: 21-AS-20230831165745
FACILITY NAME:TAMALPAISFACILITY NUMBER:
210102761
ADMINISTRATOR:TUMBALE, TERENCEFACILITY TYPE:
741
ADDRESS:501 VIA CASITASTELEPHONE:
(415) 461-2300
CITY:GREENBRAESTATE: CAZIP CODE:
94904
CAPACITY:341CENSUS: DATE:
10/09/2023
ANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Paul FriesenTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Provider failed to notify residents and post a summary of the plans and application as required by Health and Safety Code Section 1779(e)
INVESTIGATION FINDINGS:
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Complainant alleges that the Provider’s SNF Closure Application, resulted in violation of Health and Safety Code Section 1779(e) which states that, “Within 10 days of submitting an application for a certificate of authority pursuant to paragraph (3), (4), (7), or (8) of subdivision (a), the provider shall notify residents of the provider's existing community or communities of its application… A summary of the plans and application shall be posted in a prominent location in the continuing care retirement community so as to be accessible to all residents and the general public, indicating in the summary where the full plans and application may be inspected in the continuing care retirement community..” because provider failed to provide notification to residents nor posted a summary of the plans and the application in a prominent location in the community, within 10 days of the application.

The Department’s investigation determined that the Department received notification in writing on June 5, 2023, of The Tamalpais’s intention and plan to convert its skilled nursing facility to assisted living and memory care; however, this application/notification was provided under HSC 1789. On September 5, 2023, the Department received an abbreviated application from The Tamalpais to delicense some of its skilled nursing facility (SNF) beds to be converted to RCFE beds. On September 12, 2023, provider sent out notification to Tamalpais residents and Resident Council with notification that the application has been filed, the notification also included the location at the community where the application, summary and plans were posted in compliance with HSC 1779(e); therefore, the Department finds the allegation “unsubstantiated”.

LIC9099 delivered telephonically (Jennifer Walden, Allison Nakatomi and Paul Friesen), emailed, and signed copied emailed
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Allison NakatomiTELEPHONE: (916) 531-5336
LICENSING EVALUATOR NAME: Jennifer WaldenTELEPHONE: (916) 651-8148
LICENSING EVALUATOR SIGNATURE:

DATE: 10/09/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/09/2023
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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