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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 210102761
Report Date: 07/05/2023
Date Signed: 07/24/2024 12:53:28 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/10/2023 and conducted by Evaluator Christina Hadley
COMPLAINT CONTROL NUMBER: 21-AS-20230410093217
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:
07/05/2023
UNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:TIME COMPLETED:
03:07 PM
ALLEGATION(S):
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9
Provider is in violation of the Continuing Care Residence and Servies Agreement (HSC 1771(I))
INVESTIGATION FINDINGS:
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5
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Complainant alleges that the Provider’s proposed plan to close its skilled nursing facility (SNF) is in violation of H&SC section 1771(l) which states that, “… Care shall be provided under a life care contract in a continuing care contract in a continuing care retirement community having a comprehensive continuum of care, including a skilled nursing facility, under the ownership and supervision of the provider on or adjacent to the premises.” The Department’s investigation determined that the Department was notified in writing, in February 2023 of the intention to close the Skilled Nursing Facility at Sequoia Living, Inc., The Tamalpais. However the Department did not receive an application for the conversion until June 5, 2023. On June 22, 2023, the Department verified there are 202 residents with Life Care Contracts.

Per the licensee, they have had discussions with residents regarding an intention to close the SNF and had send written notifications dated June 2, 2023 to the residents of the proposed closure date in September 2023, that closure has not yet occurred. (Con't.....)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Allison NakatomiTELEPHONE: (916) 531-5336
LICENSING EVALUATOR NAME: Christina HadleyTELEPHONE: (916) 651-7853
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 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
04/10/2023 and conducted by Evaluator Christina Hadley
COMPLAINT CONTROL NUMBER: 21-AS-20230410093217

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:
07/05/2023
UNANNOUNCEDTIME BEGAN:
03:06 PM
MET WITH:TIME COMPLETED:
03:07 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Provider is in violation of the Continuing Care Residence and Servies Agreement (HSC 1771(I))
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Page 2 (Con't....)

Licensee stated they are aware that they must comply with Health and Safety Code sections 1771 (l) and 1778 (b) (1-5) that there shall be a comprehensive continuum of care, including a skilled nursing facility, under the ownership and supervision of the provider on or adjacent to the premises. On June 5, 2023, the Provider submitted an application to the Department to convert the skilled nursing facilities to assisted living units and to close the skilled nursing facility, however, at this time the Department is unable to approve the plan. Therefore, the Department finds the allegation “unsubstantiated” since the NF remains open.

(This complaint finding was completed on behalf of AGPA Jennifer Walden)

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Allison NakatomiTELEPHONE: (916) 531-5336
LICENSING EVALUATOR NAME: Christina HadleyTELEPHONE: (916) 651-7853
LICENSING EVALUATOR SIGNATURE:

DATE: 07/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2