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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 03/27/2024
Date Signed: 03/27/2024 03:47:40 PM


Document Has Been Signed on 03/27/2024 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
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: 88DATE:
03/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:ED, Corrine Tanchoco and RSD Jocelyn VahleTIME COMPLETED:
04:00 PM
NARRATIVE
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At approximately 1:00PM Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced to conduct a case management inspection. LPA followed up on Incident Reports that occurred on 03/08/2024 and 03/14/2024 and a self reported SOC341 (Suspected Dependent Adult/ Elder Abuse) that occurred on 02/28/2024. LPA met with Executive Director (ED), Corrine Tanchoco and Resident Service Director (RSD), Jocelyn Vahle.

SOC341 dated 02/28/2024: SOC341 states that Staff #1 (S1) went into Resident #1s (R1s) apartment to provide a bathroom reminder. When R1 saw S1 approaching them, R1 became agitated and punched S1 in the throat. S1 called RSD to the apartment and R1 admitted to punching S1. R1 stated that they believed S1 was going to take them to the bathroom and sexually assault them. R1 stated that they were upset that staff comes into their room to change their incontinence briefs and touch their genitals. RSD and ED confirmed that R1 has been having an increase in agitation and hallucinations due to R1s Parkinsons diagnosis.

Per R1's physicians report that was conducted before move-in, R1 has a diagnosis of Parkinsons disease, as well as confused/ disoriented behaviors. RSD and ED have since contacted R1s POA as well as R1s Primary Care Provider (PCP) due to a change in cognition. R1 now has a 1 on 1 caregiver in place which will continue until R1 has an evaluation with their PCP to make any necessary medication adjustments.

Incident Report dated 03/08/2024: Incident Report states that R2s wallet was reported to be missing. R2 remembered last having their wallet on Thursday afternoon when they went out of the community with their family. R2 noticed their wallet was missing on Friday morning. R2s family member helped to search R2s apartment and it was located at the bottom of a moving box that had not yet been unpacked, and found that there was $300 in cash missing.


Continued on LIC809C

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CREEK
FACILITY NUMBER: 216800331
VISIT DATE: 03/27/2024
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Continued from LIC809

R2s family filed a police report and the facility conducted an internal investigation. The internal investigation narrowed it down to one caregiver (Staff #2, S2) who had entered the room between Thursday and Friday. When S2 was questioned about the incident, their story was not consistent with what the facilities electronic key log revealed. S2 has since been terminated.

Incident Report dated 03/14/2024: Incident Report states that R3 was found by a housekeeper (Staff #3, S3) outside of the memory care unit waiting for an elevator to go down. RSD reviewed security footage at the time of incident and found that a culinary staff (Staff #4, S4) let R3 out of the door without realizing they were a memory care resident. R2 was outside of the memory care unit for a total of 2 minutes.

Per conversation with RSD and ED, R3 doesn't exhibit clear dementia symptoms to those who do not know them. Per review of R3s physicians report, R3 does not have a diagnosis of dementia, and does not indicate whether or not R3 can leave the facility unassisted. However, there is conflicting information with another medical document which reveals that R3 does have a dementia diagnosis. LPA confirmed with RSD that R3 cannot leave the memory care unit. LPA discussed with RSD getting an updated physicians report that reflects R3s dementia diagnosis.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, Plan of Corrections, and Appeal Rights discussed and provided to Executive Director. Signature on forms confirms receipt of documents.

SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:

DATE: 03/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 03/27/2024 03:47 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 CREEK
FACILITY NUMBER: 216800331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/28/2024
Section Cited
CCR
87705(j)

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87705 Care of Persons with Dementia
(j)The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident. This requirement was not met as evidenced by:
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Facility conducted an all staff retraining the day of the incident, and ran a drill. LPA is requesting an updated 602 reflecting R3s dementia DX. Deficiency cleared during visit.
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Based on interview and record review, the licensee did not comply with the section cited above by allowing resident to exit the memory care unit unassisted.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 03/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/27/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3