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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 210102761
Report Date: 04/25/2023
Date Signed: 04/25/2023 02:03:12 PM


Document Has Been Signed on 04/25/2023 02:03 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: 224DATE:
04/25/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Terence Tumbale, Administrator TIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shannan Hansen arrived at 8:50 AM to complete an unannounced annual inspection and met with Terence Tumbale, Administrator. There is a total of 224 residents.

LPA reviewed centrally stored medication record, and conducted staff file review and interviews to complete this annual inspection. During staff file review it was revealed Staff (S1, S2, S3, & S4) did not have required current First Aid training/certificate (see LIC809-D).

During inspection LPA followed up on medication error that was self reported to community care licensing on 4/21/2023. Resident given double dose of medication in error as staff did not check medication records. Conversation with Administrator indicated facility has scheduled medication training for staff. (see LIC809-D)

LPA Hansen is requesting facility to update and submit the following documents by 5/13/2023 to SRRO:

LIC 308 Designation of Facility Responsibility

LIC 500 Personnel Record

LIC 610 Emergency Disaster Plan (if changes)

Copy of Administrator Certificate

Proof of Liability Insurance

Appeal of Rights Given.


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..
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Shannan HansenTELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 04/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
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 04/25/2023 02:03 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: 04/25/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/28/2023
Section Cited

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 A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed.
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Facility has scheduled to conduct additional training in Medication trainig for 4/28/2023. Administrator to submit training with staff signature and date to CCL by EOB 4/28/2023.
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This requirement is not met as evidenced by:
Based on interview and record review, the licensee did not comply with the section cited above where resident was not assisted with medications per doctors orders, which poses an immediate health, safety or personal rights risk to persons in care.
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Type B
05/12/2023
Section Cited

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87411(c)(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.
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Administrator to submit proof of first aid training for S1, S2, S3, & S4 to CCL by POC 5/12/2023.
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Based on LPAs record review and interview the facility failed to ensure staff (S1, S2, S3 & S4) have first aid training which poses a potential health and saftey risk to residents in care.
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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: 04/25/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2023
LIC809 (FAS) - (06/04)
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