<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 216800331
Report Date: 03/29/2021
Date Signed: 03/29/2021 02:56:37 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
10/30/2020 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201030161818
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: DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Corrine Tanchoco - Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff fed resident foods that did not follow resident's dietary restrictions.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 11/05/2020, LPA Fernandes-Goes open the complaint investigation; acquired documentation; and conducted interviews on 3/4/21 & 03/22/21. During documentation review on file, resident R1’s POA and staff interviews LPA learned that resident has doctor’s orders for no added salt. There are no other dietary restrictions as per LIC 602 physician’s assessment dated 02/06/2020 & 01/29/2021. In addition, LPA interview outside party that confirmed that resident R1 has no dietary restrictions per doctor’s orders.
Continue LIC9099-C
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 1 of 5
Control Number 21-AS-20201030161818
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Furthermore, LPA learned that family has requested “limited daily, no acidic, or tomatoes” and Atria Tamalpais has a functional assessment from 2016 in which family requested the same. This is a family option and not a doctor’s dietary order for resident R1.

This agency has investigated the complaint alleging “Facility staff fed resident foods that did not follow resident’s restrictions.” We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.


No deficiencies cited during this inspection
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 2 of 5
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
10/30/2020 and conducted by Evaluator Carla Fernandes-Goes
PUBLIC
COMPLAINT CONTROL NUMBER: 21-AS-20201030161818

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: DATE:
03/29/2021
UNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Corrine Tanchoco - Executive DirectorTIME COMPLETED:
02:45 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff failed to follow resident's needs and care plan.
Facility staff failed to interact with residents;
Facility lacked hygiene supplies for resident;
Facility staff failed to safeguard resident's personal belongings (hearing aids, glasses);
Facility staff failed to clean resident's dentures.
Facility staff failed to inform responsible party of resident's broken dentures causing resident pain.
Facility staff member refused to take resident's temperature.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
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 11/05/2020, LPA Fernandes-Goes open the complaint investigation; acquired documentation; and conducted interviews on 3/4/21 & 03/22/21. During documentation review on file, resident R1’s POA and staff interviews, LPA learned that facility noticed a change of condition on resident R1 and on August 2, 2021 facility contacted family members regarding the need of 2 people assist. Facility doesn’t provide 2 people assist and requested family to provide one on one care. Per interview of RP on 3/4/21, resident R1 doesn’t need two people assist. Facility staff stated that facility was meeting her needs according to care plan until resident was moved out by the family.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 3 of 5
Control Number 21-AS-20201030161818
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Based on documentation reviewed (on file) and interviews (see LIC 812s), LPA wasn’t able to prove or disprove allegation reported by RP that “facility staff failed to follow resident’s” care plan.

Regarding allegation of “Facility staff failed to interact with residents.”, facility has changed interaction with residents due to COVID-19. Per staff interviews and calendar activity received from facility, all activities in August 2020 were being individualized in Life Guidance - LG (memory care) to ensure that residents with a dementia diagnostic were staying six feet apart. RP stated that during a visit it was observed residents not engaged in activities at LG unit, however; there are not enough evidence.

During review of admissions agreement and copies of receipts, LPA learned that facility has an agreement and was purchasing hygiene supplies for resident R1 due to COVID-19. RP stated that hygiene supplies were being maintained in the director’s office and weren’t made available for resident. Interviews of staff didn’t reveal that resident R1 had a lack of hygiene supply.

Per interviews of complainant/RP, family POA for Health directive, and staff on 3/4/21 and 3/22/21, facility wasn’t able to find resident’s R1 glasses and/or hearing aids which family stated that “’Resident R1’s’ insurance paid for, however; facility offered to pay” In the case of “Facility staff failed to safeguard resident's personal belongings (hearing aids, glasses)”, LPA cannot prove or disprove at this time.

In addition, complainant/RP stated that “Facility staff failed to clean resident's dentures.” and “Facility staff failed to inform responsible party of resident's broken dentures causing resident pain.”, families at the facility are to provide cleaning and hygiene supplies. Resident R1 had all hygiene and denture cleaning supplies purchased by the facility and receipts are on file. Facility provide the Department with logs of “Monthly Assignment Reports” which indicates that all ADLs needed were being provided and according with staff interviews on 3/4/21 and 3/22/21 facility procedure is to remove and clean all residents' dentures at nighttime. During the same interviews, LPA learned that facility staff had no knowledge that dentures were broken.
SUPERVISOR'S NAME: Bethany MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 4 of 5
Control Number 21-AS-20201030161818
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
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
As per staff interviews on 3/4 and 3/22/21 and facility policy # AL-001-CA, prior to COVID-19 residents “must not need monitoring of weight or vital signs.” Facility does have thermometers in the nurse’s office which can be provided for used when necessary by family members or nurse. Complainant/RP stated that when temperature of resident R1 was asked to be taken, staff stated that had no permission to do so and offered a thermometer. Facility stated that since COVID-19 March 2020, facility has been taken temperatures of residents as required by the Department.

A finding that the complaint allegations of “Facility staff failed to follow resident's needs and care plan.”; “Facility staff failed to interact with residents'.”; “Facility lacked hygiene supplies for resident.”; “Facility staff failed to safeguard resident's personal belongings (hearing aids, glasses)”; “Facility staff failed to clean resident's dentures.”; “Facility staff failed to inform responsible party of resident's broken dentures causing resident pain.”; “Facility staff member refused to take resident's temperature.”; are 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 MoellersTELEPHONE: (707) 588-5040
LICENSING EVALUATOR NAME: Carla Fernandes-GoesTELEPHONE: 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)
Page: 5 of 5