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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 08/28/2024
Date Signed: 08/28/2024 02:10:13 PM


Document Has Been Signed on 08/28/2024 02:10 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: 94DATE:
08/28/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Executive Director- Corrine Tanchoco, Resident Services Director- Jocelyn Vahle TIME COMPLETED:
02:20 PM
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At approximately 12:40PM, Licensing Program Analysts (LPAs) Loera and Felias arrived unannounced to conduct a Case Management - Incident Visit and met with Executive Director, Corrine Tanchoco, and Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

Incident Report 1: CCL received an incident report on 08/15/2024. Report stated that on 08/15/2024, facility staff observed Resident 1 (R1) on the ground. Facility notified emergency personnel who determined that R1 did not need to go to the hospital. Facility made all appropriate notifications per regulation.

Per conversation with Executive Director, R1 was on a respite plan with facility for 30 days, and has since moved out of the community.

Incident Report 2: CCL received an incident report on 08/15/2024. Report stated that on 08/15/2024, Resident 2 (R2) called emergency services to be evaluated. Facility staff notified R2's responsible party. R2 was admitted to the hospital for a urinary tract infection (UTI) and received antibiotics. Facility made all appropriate notifications per regulation.

Per conversation with Resident Services Director, R2 has been observed to be at baseline.

No Deficiencies Cited during visit.

Exit interview conducted. Copy of report and LIC811 (Confidential Names) discussed and provided to Executive Director and Resident Services Director. Signature on form confirms receipt of documents.
SUPERVISOR'S NAME: Kimberley MotaTELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony LoeraTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:
DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/28/2024
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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