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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 06/20/2023
Date Signed: 06/20/2023 04:17:48 PM


Document Has Been Signed on 06/20/2023 04:17 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:ATRIA TAMALPAIS CREEKFACILITY NUMBER:
216800331
ADMINISTRATOR:TANCHOCO, CORRINEFACILITY TYPE:
740
ADDRESS:853 TAMALPAIS AVETELEPHONE:
(415) 892-0944
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY:180CENSUS: 69DATE:
06/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Administrator, Corrine TanchocoTIME COMPLETED:
04:30 PM
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At approximately 2:15PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Required 1 year Visit and met with Executive Director/Administrator, Corrine Tanchoco. Facility is a Residential Care Facility for the Elderly and has an approved fire clearance and capacity for 180 Non-Ambulatory Residents. Facility provides Assisted Living and Dementia Care services for Older Adults. Upon arrival, LPA was informed that there were currently 69 residents in care and 46 staff members on-site.

At approximately 2:30PM, LPA reviewed the facility's staff roster with Executive Director and found that all staff members were background cleared and associated to the facility per regulation. At approximately 3:15PM, LPA conducted a walk-though of the facility with Executive Director. LPA observed the following: The facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Facility has a mitigation plan on file. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Toxins were observed to be stored inaccessible to Residents. There was an appropriate supply of cleaning products, linens, hygiene products and paper products available for Resident use.

The facility's last fire drill was conducted May 2023. Facility's fire extinguishers were last inspected January 2023. Smoke detectors and Carbon Monoxide detectors were last inspected February 2023.

LPA unable to complete the Annual Inspection. Annual Continuation Visit to be conducted at a later date.

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2023
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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