216800331-3-29-2021-21-AS-BMOS-BZPTE9-20210402143933

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 216800331
Report Date: 03/29/2021
Date Signed: 03/29/2021 02:47:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 101 GOLF COURSE DR. STE. A-230
ROHNERT PARK, CA 94928

This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/09/2020 and conducted by Evaluator Carla Fernandes-Goes

PUBLIC

COMPLAINT CONTROL NUMBER: 21-AS-20201109141743

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:	DATE:	03/29/2021
		UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Corrine Tanchoco - Executive Director		TIME COMPLETED:	02:20 PM

ALLEGATION(S):

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Staff handled resident roughly, causing injury".

INVESTIGATION FINDINGS:

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The Department conducted a complaint investigation regarding the allegation listed above. Licensing Program Analyst Fernandes-Goes conducted a telephone visit due to COVID-19 unannounced for the purpose of closing the investigation and met with Corrine Tanchoco – Executive Director.

On 11/15/2020, LPA Fernandes-Goes open the complaint investigation; acquired documentation; and conducted interviews on 11/15/20, 12/24/20, 3/9, and 3/12/2021. During documentation review on file, resident R1’s POA and staff interviews, LPA learned that facility has conducted an investigation of staff in case and police report filed on 11/7/20 and closed on 11/25/20 states that “unable to prove that ‘staff’ inflicted unjustifiable physical pain on ‘R1’”.
Continue LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

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-20201109141743

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 CREEK	FACILITY NUMBER: 216800331
	VISIT DATE: 03/29/2021

NARRATIVE

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In addition, facility submitted a SOC 341 on 11/9/2020 regarding this case. Resident R1 has a diagnostic of MCI (Mild Cognitive Impartment) as per physician’s assessment dated 11/22/2019 and moved out of the facility due to prior family plans. Based on documentation reviewed (on file), interviews (see LIC 812s), and observations LPA wasn’t able to prove or disprove allegation reported by RP that resident R1 states that facility staff “had grabbed feet/toes and twisted” bruising them.

A finding that the complaint allegation of “Staff handled resident roughly, causing injury.” is unsubstantiated meaning that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited during this inspection.

SUPERVISOR'S NAME: Bethany Moellers	TELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-Goes	TELEPHONE: 707-588-5026
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2021

LIC9099 (FAS) - (06/04)

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