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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 09/09/2020
Date Signed: 02/26/2021 10:28:54 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928
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: 70DATE:
09/09/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
04:59 PM
MET WITH:Corrine Tanchoco - Executive DirectorTIME COMPLETED:
05:10 PM
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Licensing Program Analyst (LPA) Fernandes-Goes conducted an unannounced tele-visit inspection, on 9/9/2020 at approximately 5:00 PM in regards to an exemption denial notice dated 9/8/2020. LPA is conducting a tele-visit with Executive Director Corrine Tanchoco. The inspection is being conducted by tele-inspection due to COVID-19. The reader is advised that the LPA did not physically make a site visit. At the time of inspection there were 70 residents.

At approximately 5:00 PM Executive Director stated that individual I1 is not working at the facility and ED understands that an exemption will be required if the staff is to be hired and associated to the facility.

Based on evidence obtained during today’s visit, the LPA has verified the individual is not present, employed, or residing at the facility. LPA has advised the licensee to disassociate the individual from their roster and submit an updated LIC 500.



Verification of removal is complete.

No citations issued during today's visit.
SUPERVISOR'S NAME: Carla MartinezTELEPHONE: (707) 588-5026
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: (707) 588-5026
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2020
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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