216800331-6-1-2022-21-AS-CFGS-CEYM8X-20220601092353

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 05/31/2022
Date Signed: 06/01/2022 09:24:03 AM

Document Has Been Signed on 06/01/2022 09:24 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:	ATRIA TAMALPAIS CREEK		FACILITY NUMBER:	216800331
ADMINISTRATOR:	TANCHOCO, CORRINE		FACILITY TYPE:	740
ADDRESS:	853 TAMALPAIS AVE		TELEPHONE:	(415) 892-0944
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	180	CENSUS: 75	DATE:	05/31/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Jocelyn Vahle - Residents Service Director		TIME COMPLETED:	02:30 PM

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	Licensing Program Analysts (LPA) Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Jocelyn Residence Service Director. There were 75 residents present at the facility of a max capacity of 180. There were 12 residents under hospice. Facility has activities planned for residents during the day. LPA arrived at the facility and had their temperatures checked and logged. All staff are temperature checked and logged each shift and wear masks. LPA toured the facility with Jocelyn Residence Service Director. During tour on 5/31/2022 facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 1/2022 at the time of the visit. A sample smoke detectors & carbon monoxide detector were found to be operational during the visit. Smoke detectors and fire sprinklers are inspected, and inspection records are current with the last inspection being conducted on 2/3 and 3/25/2022. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Facility kitchen has a binder and posted on the wall with all resident’s names, pictures, and their needs. Food is available for residents any time of the day. Toxins are stored in a locked housekeeping room. Hot water temperature measured upstairs between 115.7 degrees F and 119.6 degrees F within acceptable regulations of 105 to 120 degrees F in 9 of 9 resident’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Continued LIC 809-C

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

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: ATRIA TAMALPAIS CREEK	FACILITY NUMBER: 216800331
	VISIT DATE: 05/31/2022

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Infection Control:
Facility has submitted a mitigation program plan that has been approved. Some posters have been placed at entrance and residents' bathrooms. Facility has hand sanitizer available for visitors. Staff before coming into work have temperature checked. Facility has PPE supply stored in storage room – 1^st floor. There has been new staff hired and new resident’s admitted since COVID. Residents’ medications are stored and locked in medication room cart. Facility has a 30-day supply of medication for clients. Residents are not wearing masks inside the facility, however; staff stated that they are able to wear masks when going on outings. All staff had masks on during this visit. In addition, facility has a designated area for visitors which are being allowed. Residents have also available virtual and telephone calls when contacting with family members and others. Staff have had all PPE training required on file and have acquired N-95 fit testing for staff.

In addition, Department conducted an investigation regarding an SOC 341 – Suspected Dependent Adult/Elder Abuse that occurred on 5/16/2022. Facility at this time has staff S1 suspended pending investigation. During this investigation Department learned that police was contacted and has conducted. Staff S1 has never had any other episode/situation of abuse and/or suspension and has worked for this facility since 2016. Copy of all trainings have been provided to Department and are current. Resident R1 has had shingles and is under hospice care at this time due to severe pain.

There were no deficiencies cited at this time.

Department is requesting facility to submit the following update documents by 6/7/2022:

LIC 308 Designated
LIC 500 Personnel Summary
LIC 610 Emergency Disaster Plan
LIC 610E-S Supplemental Emergency Disaster Plan for RCFE
LIC 9020 Register of Facility Client’s/Resident’s
Copy of Certificate of Liability Insurance
Copy of Administrator Certificate

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 05/31/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2022

LIC809 (FAS) - (06/04)

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