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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 07/12/2024
Date Signed: 07/12/2024 03:15:25 PM


Document Has Been Signed on 07/12/2024 03:15 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: 92DATE:
07/12/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Resident Service Director, Jocelyn VahleTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Helena Rummonds arrived unannounced at approximately 1:15PM to continue an annual inspection that was initiated on 07/07/2024. LPA was greeted by Resident Service Director (RSD), Jocelyn Vahle. LPA and RSD discussed the purpose of the visit.

Medications and medication records were reviewed during visit. Medications were documented as per regulation. LPA observed residents engaged in various activities throughout the inspection.

No deficiencies cited during inspection.

Exit interview conducted. Copy of report discussed and provided to RSD. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Victoria BertozziTELEPHONE: (707) 588-5059
LICENSING EVALUATOR NAME: Helena RummondsTELEPHONE: (707) 588-5057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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