216800331-6-23-2021-21-AS-SHAN-C49PC5-20210623111122

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 06/23/2021
Date Signed: 06/23/2021 11:11:36 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 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: 80	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Corrine Tanchoco ED		TIME COMPLETED:	11:10 AM

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	Licensing Program Analysts (LPAs) Shannan Hansen & Fernandes-Goes conducted an unannounced Annual Required – 1 yr. Infection Control inspection to this facility and was welcomed by Corrine Tanchoco Executive Director & Jocelyn Residence Service Director. There were 80 residents present at the facility of a max capacity of 180 (LG-17 & AL-63). LPAs arrived at the facility and had their temperatures checked and logged. All staff are temperature checked and logged each shift and wear masks. LPAs toured the facility with Corrine Tanchoco Executive Director & Jocelyn Residence Service Director. During tour on 6/23/2021 with Corrine T. ED & Jocelyn RSD facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Resident’s bedrooms, common areas, kitchen & food storage areas were inspected. Fire Extinguishers were found to be last charged on 1/2021 at the time of the visit. A sample of 2 out of 2 Smoke Detectors & Carbon monoxide detectors were found to be operational during the visit. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Facility staff understands that food stored in the kitchen refrigerator must be properly stored as per regulations. Hot water temperature measured upstairs between 118. degrees F and 118.7 degrees F and downstairs between 117.1 degrees F and 118.9 degrees F. within acceptable regulations of 105 to 120 degrees F in 4 of 4 client’s bathroom faucets. There was a supply of cleaners, hygiene products and paper products available for residents. All resident’s bedrooms have lighting & appropriate furnishings. Infection Control: Facility has submitted a mitigation program plan that has been submitted awaiting approval at this time. Posters have been placed at facility. Facility has PPE supply stored in the upstairs and downstairs hallway closets. Residents’ medications are stored and locked. Facility has a 30-day supply of medication for residents. Residents do not wear masks inside the facility. Continue LIC 809-C

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/23/2021

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In addition, facility has a designated area for visitors outside which are being allowed for scheduled visits. Residents have also available zoom and telephone calls when contacting with family members and others. Staff had all PPE training required on file.

LPAs reviewed Licensing Information System (LIS) with staff who stated that is corrected and updated at this time. In addition, LPA advised facility to contact Marin County Public Health and DSS/CCL Community Care Licensing immediately if symptoms or COVID-19 + in the facility.

Department is requesting a copy of facility Liability Insurance to be submitted to RO Rohnert Park by June 30,2021.

There were no deficiencies cited at this time.

No citations issued

SUPERVISOR'S NAME: Kimberley Mota	TELEPHONE: (707) 588-5051
LICENSING EVALUATOR NAME: Shannan Hansen	TELEPHONE: 707-588-1410
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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