216800331-4-11-2023-21-AS-CFES-CQSQ5M-20230411115210

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:52:17 AM

Document Has Been Signed on 04/11/2023 11:52 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: 74	DATE:	04/11/2023
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Executive Director, Corrine Tanchoco		TIME COMPLETED:	11:56 AM

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	At approximately 10:00AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Corrine Tanchoco. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL). LPA reviewed the following reports with Executive Director: Incident Report 1: CCL received an incident report on 04/05/2023. The report states that on 04/04/2023, Resident 1 (R1) was observed to not be in their room when care staff delivered their meal. The facility immediately initiated their Elopement protocol. Resident was located by care staff outside on the street. R1 informed care staff that they went to go get a snack. Facility reviewed their security cameras to see how R1 left facility without staff notice. Facility made all appropriate notifications per regulation. LPA discussed R1 with Executive Director. Per review of R1's LIC 602/Physician's Report, R1 could leave the facility unassisted prior to elopement. Following the elopement, R1 was reassessed which determined that R1 needed a higher level of care. As of today, 04/11/2023, R1 has a private one-on-one companion as they wait for an opening in the facility's Memory Care unit. Facility has continued to communicate with R1's Responsible Party to provide additional services and placement options. Facility has updated R1's Physician's Report and Care Plan appropriately. Incident Report 2: CCL received an incident report on 04/07/2023. The report states that on 04/06/2023, Resident 2 (R2) was observed to be on the floor by care staff. Facility called Emergency Personnel to evaluate and R1 was sent to the hospital where they were diagnosed with a fractured vertebra. Facility made all appropriate notifications per regulation. Continued on LIC809C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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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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: 04/11/2023

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Continued from LIC809

LPA discussed R2 with Executive Director and Resident Services Director. Per conversation, R2's Physician reported that the fractured vertebra observed was from an injury that occurred prior to R2's move in to the facility. As of today, 04/11/2023, Facility has been administering R2's medication as prescribed to help them manage their pain and is on two hour status checks. Facility has continued to communicate with R2's Responsible Party regarding R2's care.

LPA conducted a walk through with Executive Director/Administrator.

No Deficiencies cited during visit.

Exit interview conducted. Copy of report and LIC 811 (Confidential Names) discussed and provided to Administrator. Signature on form confirms receipt of documents.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn Felias	TELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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