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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 06/03/2020
Date Signed: 06/03/2020 12:01:40 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
FACILITY NAME:ATRIA TAMALPAIS CREEKFACILITY NUMBER:
216800331
ADMINISTRATOR:TANCHOCO, CORRINEFACILITY TYPE:
740
ADDRESS:853 TAMALPAIS AVETELEPHONE:
(415) 892-0944
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:180CENSUS: 78DATE:
06/03/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Corrine Tanchoco - Executive DirectorTIME COMPLETED:
11:06 AM
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LPA Fernandes-Goes conducted a case management unannounced telephone call visit due to COVID-19 to discuss observations made during a complaint investigation visit that occurred on 3/10/2020 and met with Executive Director Corrine Tanchoco.

During the course of the investigation LPA Carla Fernandes-Goes learned that resident R1 per physician’s report (LIC 602) that dated 2/20/2020 has a diagnostic of dementia and is not allowed to store and/or administer his/her own medications. On 3/10/2020 LPA tour resident’s R1 apartment at the facility and observed unlocked toxins under the bathroom sink, and a couple of unlocked over the counter (OTC) medications in bathroom sink. (pictures on file) Executive Director was made aware of the fact and all medications and toxins were removed and locked during the visit. The Department is advising facility to ensure that residents with a diagnostic of dementia, and/or not allowed to store and/or administer his/her own medications, shall have these items stored inaccessible as per Title 22 Regulations # 87705 Care of Persons with Dementia and #87465 Incidental Medical and Dental Care. Facility must ensure health and safety of residents at all times.



There were no deficiencies cited at this time.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 06/03/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2020
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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