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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 06/27/2023
Date Signed: 06/27/2023 04:14:45 PM


Document Has Been Signed on 06/27/2023 04:14 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:
06/27/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Administrator, Corrine TanchocoTIME COMPLETED:
04:20 PM
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At approximately 9:15AM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct an Annual Continuation Visit and met with Executive Director/Administrator, Corrine Tanchoco. Upon arrival, LPA was informed that there were currently 69 Residents in care.

At approximately 9:40AM, LPA reviewed a sample size of 6 staff files and 6 Resident Files. Resident and Staff files were all found to be well organized, thorough and contained the required documentation. Administrator's Certificate (6003554740) was current with an expiration date of 02/26/2024.
At approximately 12:30PM, LPA conducted a walk through of the facility. A sample size of 8 sinks were tested. LPA found that hot water temperatures were within Title 22 regulations of 105 to 120 degrees Fahrenheit.
At approximately 1:00PM, LPA reviewed a sample size of 6 Resident medication records. Medication was observed to be centrally stored and secure. At approximately 3:00PM, LPA conducted staff and resident interviews.

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: 06/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/27/2023
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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