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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 05/15/2025
Date Signed: 05/15/2025 03:32:42 PM

Document Has Been Signed on 05/15/2025 03:32 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/
DIRECTOR:		TANCHOCO, CORRINEFACILITY TYPE:
740
ADDRESS:853 TAMALPAIS AVETELEPHONE:
(415) 892-0944
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 180TOTAL ENROLLED CHILDREN: 0CENSUS: 108DATE:
05/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:05 AM
MET WITH:Executive Director, Corrine Tanchoco
Resident Services Director, Jocelyn Vahle 		TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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05/15/2025, Licensing Program Analyst (LPA) Loera conducted an unannounced Annual Required – 1 yr. inspection visit for this facility and met with Executive Director, Corrine Tanchoco and Resident Services Director, Jocelyn Vahle. Facility has an emergency disaster plan as required. Facility has an infection control plan as required. There are currently 108 residents in care. Out of 108 residents, 91 residents are in Assisted Living and 17 are in Memory Care. Facility approved/cleared for 180 non-ambulatory which 5 may be bedridden and hospice waiver approved for 20.

LPA and Executive Director toured the building and grounds. The facility was found to be at a comfortable temperature. LPA observed a 2 day supply of perishable and 7 day supply of non-perishable food. LPA observed a list in the kitchen of residents who have food dietary restrictions.

All rooms were furnished per regulation. Water temperature in sinks accessible to residents in care were measured and found to be within the range of 105 to 120 degrees F. Fire extinguishers were last inspected 01/2025. Facility has fire alarms that are hard wired to the fire department and were last inspected on 05/05/2025. Facilities smoke detectors were last inspected on 05/05/2025. Facilities last fire/disaster drill was conducted on 05/08/2025.

Facility has multiple activity rooms, a salon, and a gym. All are accessible to residents.

Medications were found to be centrally stored. LPA conducted spot medication count and found all prescription medication to be properly recorded on the Centrally Stored Medication Record.

continued on LIC809-C

Kimberley MotaTELEPHONE: (707) 588-5071
Anthony LoeraTELEPHONE: (707) 588-5026
DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/15/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/15/2025
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LPA conducted a review of 10 resident records (5 Assisted Living and 5 Memory Care). All records had the required documentation.

LPA conducted review of 10 staff records/training. Upon a review of staff records, LPA found all staff to have required training and current 1st Aid & CPR certification on file.

No deficiencies cited during today's inspection. Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 06/16/2025:



LIC500- Personnel Report
LIC308- Designation of Responsibility
Updated liability Insurance

Exit interview conducted with Executive Director and a copy of this report was provided.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2025
LIC809 (FAS) - (06/04)
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