210102761-3-14-2022-21-AS-SHAN-CCHQJQ-20220314121307

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 03/14/2022
Date Signed: 03/14/2022 12:13:20 PM

Document Has Been Signed on 03/14/2022 12:13 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:	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: 296	DATE:	03/14/2022
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator Terence Tumbale		TIME COMPLETED:	12:08 PM

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	License Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Required – 1 year Infection Control Inspection of the facility. LPA was welcomed by front desk who contacted Administrator, Terrance Tumbale for the visit. There is a total of 21 assisted living residents and 240 independent living residents and 35 in the skilled nursing facility. One resident in Assisted Living is on Hospice. The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing on all floors. The assisted living setting is on the second floor. The facility also has a skilled nursing setting that is not licensed by Community Care Licensing. LPA toured the assisted living part of the facility on March 14, 2022 at 9:30 AM with Administrator, Terrance Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguisher was found to be last charged on March 7, 2022. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occurs. Hot water temperature measured between 115.3 degrees F and 125.6 degrees F falling out of Title 22 acceptable regulation of 105 to 120 degrees F in 5 of 8 resident’s bathrooms while touring facility on 3/14/2022 at 09:30 AM. (see LIC 809-D). Administrator contacted facility service director Stewart Dalie to adjust water temperature while LPA was touring facility. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area with Executive Director and learned that there are provisions made for individuals/residents with special dietary needs. Report continued on LIC 809C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

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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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: 03/14/2022

NARRATIVE

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Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There is supply of cleaners, hygiene products and paper products available for residents.

Infection Controle:

Facility has submitted a mitigation program plan that has been approved, on 4/19/2021. All staff and visitors check in and log temperatures and either have proof of vaccination on file or show proof of a negative COVID test within the last 72 hours. Posters have been placed at facility. Facility has PPE supply stored in basement. Staff had all PPE training required as well have been N95 Fit Tested. All but 1 staff has received their COVID booster shot and the one has an exemption letter on file and tests weekly.

Facility conducted last disaster drill in 12/2021.

LPA reviewed Licensing Information System (LIS) with Administrator who stated that email needs to be updated. LPA advised facility to contact Local County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

LPA was presented with proof of CPR & 1^st Aid certification for staff.

LPA viewed Administrator NHA Certificate for Terrance Tumbale #6051324740 Expiration 02/25/2023

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.

Appeal of Rights Given

LPA Hansen is requesting Licensee to update and submit the following documents by 4/14/2022 to RPRO:

LIC 308 Designated

LIC 500 Personnel Summary

LIC 610 Emergency Disaster Plan

LIC 610E-S Supplemental Emergency Disaster Plan

LIC 9020 Register of Facility Resident’s

Copy of Administrator Certificate

Proof of Liability Insurance

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/14/2022 12:13 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/14/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

This requirement is not met as evidenced by: 87303(e)(2) Maintenance & Operation.Hot water provided for the use of residents shall be maintained between 105 and 120 degrees F. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	*Based on observation the licensee failed to have hot water temperature between 105 & 120 F in 5 of 8 resident's bathrooms which poses an immediate Health, Safety risk for residents in care. LPA toured the facility w/ adm. and observed that 5 of the 8 hot water temperature ranged between 123.0 and 125.6 degrees F.
	POC Due Date: 03/15/2022
	Plan of Correction
1 2 3 4	Licensee to ensure water temperature is maintained within regulation - 105 TO 120 F. As per Administrator who informed services director Stewart Dalie hot water temperature has been adjusted during the visit. Facility to begin monitoring for the next 7 days. Licensee to submit a 7 day log taken from the resident's bathrooms to CCL by 3/25/2022. ***Licensee adjust the hot water heater during the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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	TELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2022

LIC809 (FAS) - (06/04)

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