210102761-7-6-2026-21-AS-BMOS-DW8VDN-20260722162100

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 210102761
Report Date: 07/06/2026
Date Signed: 07/06/2026 02:36:46 PM

Substantiated

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
04/21/2026 and conducted by Evaluator Julie Florio

COMPLAINT CONTROL NUMBER: 21-AS-20260421133334

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: 299	DATE:	07/06/2026
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Victoria Mozaffari-Yazdi, Nurse Manager		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not ensure that required poster is properly posted

INVESTIGATION FINDINGS:

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

On 07/06/2026, at approximately 11:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver findings regarding the allegation that staff do not ensure that required poster is properly posted as indicated on LIC802 - Complaint Report #21-AS-20260421133334, which was received by Community Care Licensing (CCL) on 04/21/2026. LPA met with Victoria Mozaffari-Yazdi, Nurse Manager.

On 04/28/2026, LPA made observations, obtained documents, and conducted interviews. During the inspection, the required Community Care Licensing Complaint/Reporting Poster (PUB 475) was observed posted on a wall in the main entryway where it was not readily visible to residents, visitors, and the public upon entering the facility.

Continued on LIC9099C...

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

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 5

Control Number 21-AS-20260421133334

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAMALPAIS	FACILITY NUMBER: 210102761
	VISIT DATE: 07/06/2026

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

Continued from LIC9099...

LPA observed kitchen staff wearing the proper hair nets, aprons, and gloves and flowing proper food handling and hand hygiene protocols. LPA further observed kitchen counters and food preparation surfaces kept clean. LPA further observed food stored in accordance with regulation regarding proper food storage and food labeling. During the same visit, LPA conducted interviews with staff regarding potential incidents with residents or complaints from residents regarding the way they are spoken to. LPA was unable to gain any information or verify any concerns that would support any resident being spoken to inappropriately.
On 06/15/2025, LPA interviewed RP who was unable to provide any documentation proof that the alleged food poisoning occurred or any evidence that staff spoke to a resident inappropriately. Based on interviews conducted and documents obtained, LPA received conflicting information and was unable to obtain any evidence that the facility is not serving food of good quality or spoke to a resident inappropriately.

Based on interviews conducted, observations made, and records obtained, the allegations that staff do not serve residents food of good quality and staff inappropriately spoke to resident are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited.

Exit interview conducted with Nurse Manager, whose signature on form confirms receipt of document(s).

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
04/21/2026 and conducted by Evaluator Julie Florio

COMPLAINT CONTROL NUMBER: 21-AS-20260421133334

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: 299	DATE:	07/06/2026
		UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Victoria Mozaffari-Yazdi, Nurse Manager		TIME COMPLETED:	02:45 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff do not serve residents food of good quality
Staff inappropriately spoke to resident

INVESTIGATION FINDINGS:

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

On 07/06/2026, at approximately 2:15 PM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver complaint investigation findings regarding LIC802 - Complaint Report #21-AS-20260421133334, which was received by Community Care Licensing (CCL) on 04/21/2026. Reporting Party (RP) alleges that staff do not serve residents food of good quality and staff inappropriately spoke to resident. LPA met with Victoria Mozaffari-Yazdi, Nurse Manager.

On 04/28/2026, LPA made observations, obtained documents, and conducted interviews with facility staff. During the inspection, LPA observed multiple fresh food stations for both hot a cold food available for residents to serve themselves as well as a full menu of items available to order from the kitchen. LPA observed cold food maintained chilled or on ice and hot foods maintained on temperature regulated heating systems which are checked routinely per observed temperature monitoring logs.

Continued on LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

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 5

Control Number 21-AS-20260421133334

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAMALPAIS	FACILITY NUMBER: 210102761
	VISIT DATE: 07/06/2026

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

Continued from LIC9099...

Additionally, the poster was observed to be displayed in a reduced-size format rather than the required full-size complaint poster. Therefore, the poster was not posted in a prominent location as required.

On 06/15/2026, upon LPA’s subsequent visit to the facility, LPA observed that the Licensee had corrected the deficiency by posting the required full-size Community Care Licensing Complaint/Reporting Poster in a prominent location in the facility’s main entryway. Therefore, although the deficiency is being cited today, it was verified corrected on 06/15/2026.

Based on observations made, documents obtained, and interviews conducted, the allegation that staff do not ensure that required poster is properly posted as indicated is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met.

Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D).

Exit interview conducted with Nurse Manager, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided.

SUPERVISORS NAME: Bethany Moellers
LICENSING EVALUATOR NAME: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 21-AS-20260421133334

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: TAMALPAIS	FACILITY NUMBER: 210102761
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/06/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/07/2026 Section Cited CCR 87468(c)(2)(A)	1 2 3 4 5 6 7	Personal Rights (c)Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2)(A) ....The poster that is posted shall be 20" x 26" in size and be posted in the	1 2 3 4 5 6 7	The Poster was observed in a reduced-size format rather than the required 20” x 26” size and was posted in a location where it was not readily visible upon entering the facility.
	8 9 10 11 12 13 14	main entryway of the facility. This requirement is not met as evidenced by: Based on observation, the Licensee did not prominently post the required Complaint Poster (PUB 475) in the facility’s main entryway.	8 9 10 11 12 13 14	Licensee corrected the deficiencey as observed by LPA on 06/15/2026 visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Julie Florio
LICENSING EVALUATOR SIGNATURE:	DATE: 07/06/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026

LIC9099 (FAS) - (06/04)

Page: 5 of 5