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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 02/26/2025
Date Signed: 02/26/2025 03:47:26 PM

Document Has Been Signed on 02/26/2025 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/
DIRECTOR:
TANCHOCO, CORRINEFACILITY TYPE:
740
ADDRESS:853 TAMALPAIS AVETELEPHONE:
(415) 892-0944
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 180CENSUS: 95DATE:
02/26/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:40 PM
MET WITH: Administrator, Corrine TanchocoTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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At approximately 1:40PM, Licensing Program Analysts (LPAs) Loera and Deniz arrived unannounced to conduct a Case Management - Incident Visit and met with Administrator, Corrine Tanchoco. The purpose of the visit was to follow up on self-reported incident that was submitted to Community Care Licensing (CCL).

CCL received an incident report on 11/20/2024. Report stated that on 11/19/2024, Business Office Director observed resident 1 (R1) walking in front of community and alerted Executive Director. Executive Director then escorted R1 back into the community and into memory care. Upon investigation R1 had gone out the back door of memory care around 1:55pm and was still observed in the camera at approximately 2pm. R1 was last seen making a right into the memory care backyard. R1 was not harmed or needing medical attention.

Based on conversation with Administrator, R1 went out the back door of memory care while staff were outside in the parking lot during a shift change and observed R1 to open the door in the backyard of memory care, staff then assisted R1 back into the memory care building. Facility made all appropriate notifications per regulation.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Administrator.
SUPERVISORS NAME: Kimberley Mota
LICENSING EVALUATOR NAME: Anthony Loera
LICENSING EVALUATOR SIGNATURE: DATE: 02/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/26/2025
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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