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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 03/07/2023
Date Signed: 03/07/2023 12:03:18 PM


Document Has Been Signed on 03/07/2023 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: 225DATE:
03/07/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director Paul Friesen, Director of Nursing Ellen Pearson, & MDS Coordinator Jennifer WilliardTIME COMPLETED:
12:05 PM
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Licensing Program Analyst (LPA) Hansen and Licensing Program Manager (LPM) Moellers conducted an unannounced case management and met with Executive Director Paul Friesen, Director of Nursing Ellen Pearson, & Minimal Data Set (MDS) Coordinator Jennifer Williard. The purpose of this case management inspection is to conduct a file review of 28 residents currently residing in the Skilled Nursing (SNF) portion of the facility. Facility is licensed as a Continuing Care Retirement Community(CCRC) that will be eliminating the skilled nursing facility (SNF) portion of the building.

LPA Hansen and LPM Moellers provided copies of Title 22 Regulations: 87612-Restricted Health Conditions, 87615-Prohibited Health Conditions, 87618-Oxygen Administration - Gas and Liquid


SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 03/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/07/2023
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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