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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 07/03/2024
Date Signed: 07/03/2024 02:39:55 PM


Document Has Been Signed on 07/03/2024 02:39 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
SANTA ROSA RO, 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: 92DATE:
07/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Executive Director, Corrine TanchocoTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 9:00AM to conduct an Annual Required inspection and was greeted by Executive Director, Corrine Tanchoco. There are currently 17 residents in Memory Care and 75 residents in Assisted Living.

LPA and Executive Director initiated a tour of the facility around 9:30AM and made the following observations: Facility was a comfortable temperature and passageways were free from obstructions. Resident rooms were furnished per regulation. LPA measured water temperatures in 8 sinks accessible to residents and all were within the range of 105 to 120 degrees F allowed per regulation. Extra hygiene products and linens were available. Cabinets containing cleaning supplies were locked.

Facility has at least two days of perishable and one week of non-perishable foods which were of quality and stored per regulation. Medications were centrally stored and locked. Fire extinguishers were last serviced 01/25/2024. Facility has fire alarms that are hard wired to the fire department and were last inspected on 04/03/2024. Facilities smoke detectors were last inspected on 04/16/2024. Carbon monoxide detectors located throughout the facility were tested and operational during visit. Most recent disaster drill was conducted on 02/21/2024. Facility conducts fire drills monthly.

10 AL and 5 MC files were reviewed. Reviewed files contained required documents. 10 staff records were reviewed. Staff have required First Aid and CPR certificates. Training records were reviewed. Staff have required training. Administrator Certificate for Executive Director, Corrine Tanchoco (6003554740) expired on 02/26/2024 and is now on the departments pending list.

LPA unable to complete inspection at this time. LPA to return at a later date to complete inspection.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2024
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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