216800331-2-26-2025-21-AS-KMOA-DEPRYV-20250312132654

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800331
Report Date: 02/26/2025
Date Signed: 02/26/2025 03:48:59 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/17/2024 and conducted by Evaluator Anthony Loera

COMPLAINT CONTROL NUMBER: 21-AS-20241017124159

FACILITY NAME:	ATRIA TAMALPAIS CREEK		FACILITY NUMBER:	216800331
ADMINISTRATOR:	TANCHOCO, CORRINE		FACILITY TYPE:	740
ADDRESS:	853 TAMALPAIS AVE		TELEPHONE:	(415) 892-0944
CITY:	NOVATO	STATE: CA	ZIP CODE:	94947
CAPACITY:	180	CENSUS: 95	DATE:	02/26/2025
		UNANNOUNCED	TIME BEGAN:	01:40 PM
MET WITH:	Administrator, Corrine Tanchoco		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff not properly supervising resident resulting multiple hip dislocation at the facility.

INVESTIGATION FINDINGS:

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On 02/26/2025, Licensing Program Analysts (LPAs) Loera and Deniz conducted an unannounced visit for the purpose of delivering complaint findings. LPA arrived and met with Executive Director, Corrine Tanchoco. During the course of the investigation, LPA reviewed records, conducted interviews with staff and outside parties, and made observations. Medical records were reviewed by the Departments Program Clinical Consultant.

Compliant alleges, Staff not properly supervising resident resulting multiple hip dislocation at the facility.

Based upon department interviews with staff, information provided was contradicting with a lack of corroborating evidence to support the allegation. On Residents (R1) Pre-Placement Appraisal dated 05/31/2024 notes R1 uses a walker to ambulate with and is considered non ambulatory (slow, help with bathing, dressing, and toileting). R1’s Functional Needs Service Plan that was signed by POA states under functional capabilities (3. fall risk) requires minimal assistance, (16. Transfer ability) does not require assistance, and (20. Escorting) does not require assistance.

continued on LIC9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
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.

LIC9099 (FAS) - (06/04)

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Control Number 21-AS-20241017124159

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/26/2025

NARRATIVE

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R1’s physician’s report (602) (dated 05/29/2024) mentions hip dislocation under diagnoses. This Department’s Program Clinical Consultant reviewed medical records from Marin General Hospital that show R1 had surgery on 08/18/2024 to correct the problem. Medical records revealed that after surgery on 08/19/2024 R1’s hip was corrected. Review of medical records show R1 sustained hip dislocations while doing day to day activities (walking, bending forward to pick something off floor, waking-up and trying to walk), all were non-trauma related. Medical Records also show per R1’s history, R1 underwent hip replacement surgery on 08/10/2016 after suffering a left femur fracture. R1’s hip dislocations cannot be attributed from staff neglect.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is unsubstantiated.

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5071
LICENSING EVALUATOR NAME: Anthony Loera	TELEPHONE: (707) 588-5026
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

LIC9099 (FAS) - (06/04)

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