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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 07/06/2023
Date Signed: 07/06/2023 03:47:19 PM


Document Has Been Signed on 07/06/2023 03:47 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: 73DATE:
07/06/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Administrator/Executive Director, Corrine TanchocoTIME COMPLETED:
01:45 PM
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At approximately 1:00PM, Licensing Program Analyst (LPA) Felias arrived unannounced to conduct a Case Management - Incident visit and met with Administrator/Executive Director, Corrine Tanchoco. The purpose of the visit was to follow up on a self-reported incident that was submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 05/11/2023. Report states that on 05/10/2023, Resident 1 (R1) was found on the floor by Care Staff. R1 was observed to have a bump on their head and was bleeding. Facility contacted Emergency Personnel and R1 was transported to the hospital to be evaluated. Facility made all appropriate notifications per regulation.

LPA and Executive Director discussed R1. LPA was informed that R1 was sent to stay at a Skilled Nursing Facility for Physical/Occupational Therapy due to their fall. Facility was in communication with R1, R1's Responsible Party, and Physician during R1's stay at the Skilled Nursing Facility. While R1 was at the Skilled Nursing Facility, R1's Responsible Party decided to relocate them to a Board and Care. As of today, 07/06/2023, R1 has been moved out.

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 MotaTELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Caitlynn FeliasTELEPHONE: 707-588-5039
LICENSING EVALUATOR SIGNATURE:
DATE: 07/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2023
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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