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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 06/05/2024
Date Signed: 06/05/2024 12:54:33 PM

Document Has Been Signed on 06/05/2024 12:54 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/
DIRECTOR:		TUMBALE, TERENCEFACILITY TYPE:
741
ADDRESS:501 VIA CASITASTELEPHONE:
(415) 461-2300
CITY:GREENBRAESTATE: CAZIP CODE:
94904
CAPACITY: 341CENSUS: 214DATE:
06/05/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Paul Freisen, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Shannan Hansen arrived at 10:00 AM to complete an unannounced continuation of annual inspection and met with Paul Freisen, Executive Director. There is a total of 214 residents.

LPA initiated a file review of 5 staff records and reviewed centrally stored medication records to complete this annual inspection. During staff file review at approximately 10:30 AM it was revealed facility had not requested a clearance transfer for staff (S1) who had worked at facility since 1/9/2024, LPA contacted CCL RO that confirmed (see LIC 809-D & LIC421 BG for ICP). Staff (S1 & S2) did not have required current First Aid training/certificate (see LIC809-D).

**Civil Penalty assessed in the amount of $500.00.

LPA Hansen is requesting facility to update and submit the following documents by 6/30/2024 to CCL:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

Continue on LIC809-C

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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Document Has Been Signed on 06/05/2024 12:54 PM - It Cannot Be Edited


Created By: Shannan Hansen On 06/05/2024 at 11:59 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAMALPAIS
FACILITY NUMBER: 210102761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)(2)

87355 Criminal Record Clearance- (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)

This requirement is not met as evidence by:
Deficient Practice Statement
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Based on LPAs record review and verification with CCL: Licensee did not ensure the regulation above due to S1 who was fingerprint cleared but NOT associated to this facility as required. LPA confirmed start date with staff ast 1/9/2024. This is an immediate risk to the Health & Safety of residents in care.
POC Due Date: 06/06/2024
Plan of Correction
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Licensee agrees to associate S1 to facility. Facility to submit a written statement they understand regulation 87355(e)(2) and will be in future compliance. Facility to submit statement to CCL by POC due date 06/06/2024.

**Civil Penalty assessed in the amount of $500.00.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/05/2024 12:54 PM - It Cannot Be Edited


Created By: Shannan Hansen On 06/05/2024 at 12:40 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAMALPAIS
FACILITY NUMBER: 210102761

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)

87411(c)(1) PERSONNEL REQUIREMENTS GENERAL; Staff shall receive first aid training from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on staff files review, the facility did not ensure that all staff have current 1st aid. LPA learned that 2 of 2 staff (S1 & S2) does not have proof of current first aid certification which poses a potential health & safety risk to residents in care.
POC Due Date: 06/07/2024
Plan of Correction
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Licensee to ensure that all staff have current first aid certification at all times. Licensee to submit proof of First Aid Certification for staff S1& S2 to CCL by POC date of 6/7/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bethany Moellers
LICENSING EVALUATOR NAME:Shannan Hansen
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


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: 06/05/2024
NARRATIVE
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Appeal of Rights Given.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Shannan Hansen
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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