210102761-6-2-2022-21-AS-SHAN-CEZPBB-20220602111005

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 06/02/2022
Date Signed: 06/02/2022 11:10:24 AM

Document Has Been Signed on 06/02/2022 11:10 AM - 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:	4154612300
CITY:	GREENBRAE	STATE: CA	ZIP CODE:	94904
CAPACITY:	341	CENSUS: 241	DATE:	06/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Administrator Terence Tumbale		TIME COMPLETED:	11:10 AM

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 Executive Director, Terrance Tumbale for the visit. There is a total of 241 assisted living residents and independent living residents in the facility. Two residents in Assisted Living are 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 facility on June 2, 2022 at 9:15 AM with Executive Director, 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 at an acceptable range and within Title 22 acceptable regulation of 105 to 120 degrees in the 7^th floor assisted living dinning hall, 2 assisted living and 2 independent living resident’s bathrooms while touring facility on June 2, 2022 at 9:45 AM. 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. 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. (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: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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: 06/02/2022

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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 one staff have received their COVID booster shot and the one has an exemption letter on file and tests weekly.

Facility conducted last disaster drills in 12/2021.

LPA reviewed Licensing Information System (LIS) with Administrator who stated all is up to date, nothing needs to be changed. 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 Certificate for Terrance Tumbale #6051324740 Expiration 02/25/2023

No deficiencies were observed or cited during today's Required 1- Year inspection. Exit interview was conducted and a copy of this report was emailed to the Facilities Executive Director, Terence Tumbale

LPA Hansen is requesting Licensee to update and submit the following documents by 6/17/2022 to SRRO:

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: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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