216800331-4-11-2023-21-AS-KMOA-CQUPDE-20230413111322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800331
Report Date: 04/11/2023
Date Signed: 04/11/2023 11:50:55 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/28/2022 and conducted by Evaluator Caitlynn Felias

COMPLAINT CONTROL NUMBER: 21-AS-20221228152105

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
		UNANNOUNCED	TIME BEGAN:	09:15 AM
MET WITH:	Executive Director, Corrine Tanchoco		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Neglect/Lack of supervision resulting in resident sustaining severe injuries and hospitalization

INVESTIGATION FINDINGS:

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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced on 04/11/2023 to deliver findings regarding the above allegation. LPA met with Executive Director, Corrine Tanchoco.

During the investigation, the Department conducted interviews, reviewed documents, and made observations.
There was an allegation that Neglect/Lack of supervision resulted in resident sustaining severe injuries and hospitalization. Reporting Party (RP) reported that Resident 1 (R1) suffered a ground level fall onto their left side and sustained a left femoral neck fracture and a left clavicle fracture resulting in surgery.
During the investigation, the Department learned that R1 was sent to the hospital after a witnessed fall when R1 attempted to stand while using a walker in a common area of the facility. R1 was sent to the hospital and underwent hip surgery. R1 was additionally diagnosed with a left clavicle fracture; seventh and eighth rib fractures (age indeterminate, likely acute); and a mildly impacted left femoral neck fracture, with no evidence of hip dislocation. R1 was discharged to a skilled nursing facility, and later returned to the facility.
Continued on LIC809C

Unsubstantiated

Estimated Days of Completion:

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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20221228152105

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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

NARRATIVE

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Continued from LIC809

R1 gave conflicting statements about having a walker at the time of the fall. R1 reported that they lost their balance and fell. R1’s DPOA did not recall anytime that they visited R1, that R1 did not have their walker. Staff gave conflicting statements regarding the placement of the walker. Staff 1 (S1) who was in the area at the time of the fall, but was assisting another resident, reported that R1 had their hands on the walker at the time of the fall. R1's Needs and Services Plan states that they are to have their walker near them. In addition, the facility has put additional fall risk prevention procedures in place for R1.

A finding that the complaint allegation of “Neglect/Lack of supervision resulting in resident sustaining severe injuries and hospitalization” is UNSUBSTANTIATED.
A finding that the complaint is Unsubstantiated means that although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report 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

LIC9099 (FAS) - (06/04)

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