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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 08/06/2024
Date Signed: 08/06/2024 09:24:45 AM


Document Has Been Signed on 08/06/2024 09:24 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: 247DATE:
08/06/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Terence Tumbale, AdministratorTIME COMPLETED:
09:30 AM
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Terence Tumbale, Administrator.

LPA conducted a walk through of facility at 9:00am, made observations and obtained additional information regarding the transitioning of the Skilled Nursing Facility (SNF) beds to Assisted Living (AL) in Residential Care Facility for the Elderly (RCFE). Administrator will be submitting additional requested documentation.

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: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/06/2024
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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