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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 216800331
Report Date: 01/06/2026
Date Signed: 01/06/2026 03:13:19 PM

Document Has Been Signed on 01/06/2026 03:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 CREEKFACILITY NUMBER:
216800331
ADMINISTRATOR/
DIRECTOR:		TANCHOCO, CORRINEFACILITY TYPE:
740
ADDRESS:853 TAMALPAIS AVETELEPHONE:
(415) 892-0944
CITY:NOVATOSTATE: CAZIP CODE:
94947
CAPACITY: 180CENSUS: 108DATE:
01/06/2026
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:20 PM
MET WITH:Executive Director, Corrine Tanchoco
Resident Services Director, Jocelyn Vahle		TIME VISIT/
INSPECTION COMPLETED:
03:25 PM
NARRATIVE
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Licensing Program Analyst (LPA) Loera arrived unannounced to conduct a Case Management - Incident visit and met with Executive Director, Corrine Tanchoco, Resident Services Director, Jocelyn Vahle. The purpose of the visit was to follow up on self-reported incidents that were submitted to Community Care Licensing (CCL).

CCL received three incident reports on 12/04/2025. Incident report #1 states on 12/03/2025, during an incident investigation staff (S1) verbalized to staff (S2) that on 12/02/2025 during S1s shift training of a new staff (S3), S3 did not give resident (R1) narcotic medications. It was reported they attempted to pass the medication while R1 was in the dining room and another staff stopped them. They then took the medication back to the cart and locked it in the top drawer. Later when R1 was ready for medication they only dispensed R1s non narcotic medications and omitted the narcotics from administration.

Incident report #2 states on 12/03/2025, S2 went to resident's (R2) room after getting report from staff that R2 was not feeling was and reported R2 was given two doses of medication the night before. R2 reported having new staff given them medication and then seeing their normal med tech. S2 called 911 and R2 was transported to the hospital for further evaluation.

Incident report #3 states on 12/03/2025, at approximately 6:30am staff called and reported to S2 that resident's (R3) Alprazolam had been tampered with. It was observed on the #7 bubble pill that Alprazolam was removed and replaced with mirtazapine tablet and taped back up.

LPA was informed S1 and S3 were both terminated as of 12/08/2025.

Deficiencies are cited from the California Code of Regulations (CCRs), and/or the Health and Safety Code. Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Exit interview conducted. Copy of report, LIC809D, LIC811, and Appeal Rights discussed and provided to Executive Director.

NAME OF LICENSING PROGRAM MANAGER: Kimberley Mota
NAME OF LICENSING PROGRAM ANALYST: Anthony Loera
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 01/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 01/06/2026 03:13 PM - It Cannot Be Edited


Created By: Anthony Loera On 01/06/2026 at 02:06 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: ATRIA TAMALPAIS CREEK
FACILITY NUMBER: 216800331

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/06/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/07/2026
Section Cited
CCR
87465(a)

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Incidental Medical and Dental Care 87465(a)(4) The licensee shall assist residents with self-administered medications as needed.

This requirement not met by licensee as evidenced by:
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Facility conducted medication in-service training for medication technicians on 12/04/2025. Deficiency cleared at time of visit.
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Based on document review; R1 did not receive their narcodic medication, R2 received two doses of the same medication, and R3s mediciation were tampered with which poses an immediate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kimberley Mota
NAME OF LICENSING PROGRAM MANAGER:
Anthony Loera
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 01/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/06/2026


LIC809 (FAS) - (06/04)
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