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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 02/02/2023
Date Signed: 02/02/2023 12:03:24 PM


Document Has Been Signed on 02/02/2023 12:03 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:TUMBALE, TERENCEFACILITY TYPE:
741
ADDRESS:501 VIA CASITASTELEPHONE:
(415) 461-2300
CITY:GREENBRAESTATE: CAZIP CODE:
94904
CAPACITY:341CENSUS: 230DATE:
02/02/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Administrator Terence Tumbale & Executive Director Paul FriesenTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Hansen conducted an unannounced case management and met with Terence Tumbale, Administrator. The purpose of this case management inspection is to follow up on 3 self reported SOC 341's submitted to Community Care Licensing (CCL).

CCL received 3 self reported SOC 341 forms on 1/26/2023 reporting on 1/25/2023 and for the past two weeks S1 was reported by resident R1, R2, and R3, to have been verbally aggressive with residents. S1 has been suspended pending investigation. Submitted reports cross reported to Local Ombudsman, DOJ and responsible parties. LPA made copies of internal investigation notes, records, conducted interviews and made observations. Administrator agrees to inform LPA when internal investigation is complete and how facility is going to proceed regarding alleged abuse reported.

During investigation LPA identified (S1) did not have criminal record clearance as required, to be working in a facility. Facility being cited under 87355(e)(1)(see LIC 809-D).

***An immediate civil penalty was assessed in the total amount of $500

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

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SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
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 02/02/2023 12:03 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: 02/02/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/03/2023
Section Cited

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87355 Criminal Record Clearance: (e) All individuals subject to a criminal record review...shall prior to working, residing or volunteering in a licensed facility: (1) Obtain a California clearance...as required by the Department...
This requirement was not met as evidenced by:
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(S1)'s last day working in the facility was 1/24/2023. Administrator to submit a written statement that they understand the regulation and will be in future compliance. Statement to be submitted to CCL by POC due date 01/03/2023.
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Based on records reviewed, Administrator did not ensure the above regulation due to staff (S1) working and providing services in the facility without a fingerprint clearance as required. This is an immediate health, safety, and personal rights risk to residents in care.
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***An immediate civil penalty was assessed in the total amount of $500

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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 MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2023
LIC809 (FAS) - (06/04)
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