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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 05/16/2024
Date Signed: 05/16/2024 02:16:21 PM


Document Has Been Signed on 05/16/2024 02:16 PM - 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: 229DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Terence Tumbale, AdministratorTIME COMPLETED:
02:20 PM
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License Program Analyst (LPA) Hansen arrived unannounced to conduct a required annual inspection of facility and was welcomed by front desk. LPA met with Administrator Terence Tumbale for the visit. There is a total of 26 assisted living & memory care residents, and 203 independent living residents. There are two residents currently on Hospice & 8 residents have a dementia diagnosis.

The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing (CCL) on all floors. The assisted living and Memory Care units are on the second floor. The facility also has a skilled nursing setting that is not licensed by CCL.

LPA toured the facility on 5/16/2024 at 9:00 AM with administrator, Terence Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on 3/6/2024 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. 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 107 degrees F and 118.4 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 13 of 13 assisted living, independent living, and memory care resident’s bathrooms while touring facility on 5/16/2024 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 5/16/2024 at 11:15 AM with administrator Terence 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: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/16/2024
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, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: TAMALPAIS
FACILITY NUMBER: 210102761
VISIT DATE: 05/16/2024
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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.

Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.”


At 12:30 MP 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: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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