210102761-12-30-2021-21-AS-BMOS-CAC25P-20220103160550

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102761
Report Date: 12/30/2021
Date Signed: 12/30/2021 09:48:52 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/19/2021 and conducted by Evaluator Shannan Hansen

COMPLAINT CONTROL NUMBER: 21-AS-20211019114116

FACILITY NAME:	TAMALPAIS		FACILITY NUMBER:	210102761
ADMINISTRATOR:	TUMBALE, TERENCE		FACILITY TYPE:	741
ADDRESS:	501 VIA CASITAS		TELEPHONE:	(415) 461-2300
CITY:	GREENBRAE	STATE: CA	ZIP CODE:	94904
CAPACITY:	341	CENSUS:	DATE:	12/30/2021
		UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Terence Tumbale - Administrator		TIME COMPLETED:	09:50 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility is not following their Program Plan - AL and memory care residents are not receiving services as laid out in the facilities Program Plan.

Food Services - facility is not following food service regulations

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Hansen conducted a complaint investigation regarding the allegations listed above. LPA arrived unannounced on this day for the purpose of a subsequent complaint investigation resulting in delivering findings of the above allegations. LPA met with XXX ?Terence Tumbale, Administrator.

During the investigation LPA reviewed records, made observations at the facility and conducted interviews.

LPA investigated a complaint allegation; Facility is not following their Program Plan - AL and memory care residents are not receiving services as laid out in the facilities Program Plan. This facility does not have a memory care at this time. The facilities program plan for care of residents with dementia indicates in part; The degree of dementia is assessed by a team:

Continued on 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

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 3

Control Number 21-AS-20211019114116

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TAMALPAIS	FACILITY NUMBER: 210102761
	VISIT DATE: 12/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

“Residents and Responsible Parties become involved in placement when staff or families recognize that a resident's dementia has become advanced to the point where he or she cannot live well with others, is a danger to him/herself, etc…” The facility will be undergoing renovations and the Administrator informed construction will begin at the beginning of April 2022, there were three resident meetings (9/14/2021, 9/20/2021, and 9/27/2021) where the facility discussed the Assisted Living and Memory Care (AL/MC) renovation and relocation. In addition, there was a zoom meeting set up by the Residents Care Director that took place on 10/7/2021 and another one with the CEO and Chief Development Officer. On 11/29/2021 there was a letter sent to all residents of A/L and their families regarding the change with a follow up call from the Resident Care Director (S7). LPA confirmed the five (5) residents requested to relocate prior to the move were notified and agreed to the relocation. On 12/9/2021 LPAs toured 2nd floor of facility where construction of memory care is soon to commence, and areas have started to be marked “off limits. Facility has had a full-time doctor (S5) for over ten years. In an interview with S5 LPA learned there was an agreement being put together for a new Medical Director who will be taking over when S5 retires although S5 will continue to be a consultant through January 2022. There is also an Infection Preventionist (S4) as well as a Director of Nursing Services (S6) who has been on leave but is returning on 1/3/2021 and has been employed since 2001”. Based on LPAs record review, interviews and observation no evidence to support facility is not following their program plan pending the renovations was obtained. Therefore, this allegation is unsubstantiated.

LPA investigated the complaint allegation related to food service; facility is not following food service regulations. Complaint alleges the facility has no food director and they have cut back on food services. Records reviewed and interviews conducted revealed there has been a Dinning Services Director at the facility full time. According to the current Dinning Services Director (S1) who has been at the facility since 10/8/2021, “the food menu remains the same and the facility is not modifying unless they have Special Diets.” Administrator informed prior to S1 being hired facility had an interim Dinning Services Director (S2) from 8/10/2021 to 10/7/2021. Prior to interim Food Director S3 was the Dinning Services Director whose last day was 8/16/2021. Investigation revealed facility has a full time Food Director and prior to 10/7/2021 there was not a lapse in this position being filled.

Continued on 9099-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 3 of 3

Control Number 21-AS-20211019114116

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

FACILITY NAME: TAMALPAIS	FACILITY NUMBER: 210102761
	VISIT DATE: 12/30/2021

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Facilities Infection Preventionist (S4) informed facility has been working with Marin County Dept. of Public Health. Due to COVID the facility is not offering a buffet, but the dining room is currently open to seating with restrictions. Residents can dine in or request to have food delivered or pick up. Facility is following their plan of operations, “Three nutritionally balanced meals per day are provided in the dining room. In addition, will accommodate all special diets prescribed by your personal physician as a medical necessity and approved by the staff physician. Tray Service will be provided to your unit during an illness……” Although complainant alleges facility is not following food service regulation LPA did not obtain additional information to support. LPAs investigation did reveal changes to dining service related to COVID precautions. The allegation is unsubstantiated.

A finding that the complaint allegation of; facility is not following their Program Plan - AL and memory care residents are not receiving services as laid out in the facilities Program Plan and Food Services - facility is not following food service regulations is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 12/28/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 3