Tamalpais

Allegation investigated: Staff do not ensure that required poster is properly posted

On 07/06/2026, at approximately 11:45 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to deliver findings regarding the allegation that staff do not ensure that required poster is properly posted as indicated on LIC802 - Complaint Report #21-AS-20260421133334, which was received by Community Care Licensing (CCL) on 04/21/2026. LPA met with Victoria Mozaffari-Yazdi, Nurse Manager. On 04/28/2026, LPA made observations, obtained documents, and conducted interviews. During the inspection, the required Community Care Licensing Complaint/Reporting Poster (PUB 475) was observed posted on a wall in the main entryway where it was not readily visible to residents, visitors, and the public upon entering the facility. Continued on LIC9099C... Substantiated Continued from LIC9099... LPA observed kitchen staff wearing the proper hair nets, aprons, and gloves and flowing proper food handling and hand hygiene protocols. LPA further observed kitchen counters and food preparation surfaces kept clean. LPA further observed food stored in accordance with regulation regarding proper food storage and food labeling. During the same visit, LPA conducted interviews with staff regarding potential incidents with residents or complaints from residents regarding the way they are spoken to. LPA was unable to gain any information or verify any concerns that would support any resident being spoken to inappropriately. On 06/15/2025, LPA interviewed RP who was unable to provide any documentation proof that the alleged food poisoning occurred or any evidence that staff spoke to a resident inappropriately. Based on interviews conducted and documents obtained, LPA received conflicting information and was unable to obtain any evidence that the facility is not serving food of good quality or spoke to a resident inappropriately. Based on interviews conducted, observations made, and records obtained, the allegations that staff do not serve residents food of good quality and staff inappropriately spoke to resident are UNSUBSTANTIATED. A finding that a complaint allegation is unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED. No deficiencies cited. Exit interview conducted with Nurse Manager, whose signature on form confirms receipt of document(s). Continued from LIC9099... Additionally, the poster was observed to be displayed in a reduced-size format rather than the required full-size complaint poster. Therefore, the poster was not posted in a prominent location as required. On 06/15/2026, upon LPA’s subsequent visit to the facility, LPA observed that the Licensee had corrected the deficiency by posting the required full-size Community Care Licensing Complaint/Reporting Poster in a prominent location in the facility’s main entryway. Therefore, although the deficiency is being cited today, it was verified corrected on 06/15/2026. Based on observations made, documents obtained, and interviews conducted, the allegation that staff do not ensure that required poster is properly posted as indicated is SUBSTANTIATED. A finding that a complaint allegation is SUBSTANTIATED means that the allegation is valid because the preponderance of the evidence standard has been met. Deficiency is cited from Title 22 Regulations, Division 6, (see LIC9099D). Exit interview conducted with Nurse Manager, whose signature on form confirms receipt of documents. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Jul 6, 2026 · control 21-AS-20260421133334

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87468(c)(2)(A) · Plan of correction due date: Aug 7, 2026

Personal Rights (c)Licensees shall prominently post personal rights, nondiscrimination notice, and complaint information in areas accessible to residents, representatives, and the public. (2)(A) ....The poster that is posted shall be 20" x 26" in size and be posted in the main entryway of the facility. This requirement is not met as evidenced by: Based on observation, the Licensee did not prominently post the required Complaint Poster (PUB 475) in the facility’s main entryway.the state’s words, verbatim · CDSS document, Jul 6, 2026

Plan of correction: The Poster was observed in a reduced-size format rather than the required 20” x 26” size and was posted in a location where it was not readily visible upon entering the facility. Licensee corrected the deficiencey as observed by LPA on 06/15/2026 visit.

Type of visit: Case Management - Other

On 07/06/2026, at approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a case management - incident visit and met with Victoria Mozaffari-Yazdi, Nurse Manager. LPA is following up on information obtained during an interview conducted on 06/15/2026 and subsequent documentation received via email for LIC802 - Complaint Report #21-AS-20260421133334, which was received by Community Care Licensing (CCL) on 04/21/2026 for concerns not addressed in the complaint through an official allegation. During LPA's interview with Resident 1 (R1), concerns regarding chlorine levels in the facility's pool and spa were discussed. R1 stated that the levels were causing them skin sensitivities and subsequently provided LPA with pictures. On 07/02/2026, during a subsequent facility case management - annual continuation visit, LPA obtained documents and conducted an interview with Staff 1 (S1). Based on the interview that day, it was revealed that the facility's Environmental Services staff test the chlorine, PH, and temperature levels in the pool and spa twice daily; once in the morning and once in the evening. Copies of the the daily testing logs were obtained for January 2026 through May 2026. Based on interviews and logs obtained, the facility operates in compliance with the Aquatic Counsel's national standards of chlorine levels maintained between 1 particle per million (ppm) and 10 ppm. Both revealed that due to the population served and resident feedback, the facility aims to maintain the pool chlorine levels between 3 ppm-5 ppm and the spa between 4 ppm - 6 ppm (due to increased temperature which increases the chemical burn rate). Continued on LIC809C... Continued from LIC809... Although not required, the facility posts running daily testing logs at the entrance to the pool and spa for the residents to reference at anytime, so there is full transparency about the chemical levels and residents can make an informed decision about whether to enter either. Today, on 07/06/2026, LPA observed more than one warning notice posted in the pool and spa area which mentions not entering either with rashes or skin lesions present and that persons choose to enter either at their own risk. Based on the daily testing logs obtained and interviews conducted with R1 and S1, the Department received conflicting information about the chemical levels in the facility's pool and spa. No deficiencies were cited during todays visit. Exit interview was conducted with Nurse Manager, whose signature on form confirms receipt of document.the state’s words, verbatim · CDSS document, Jul 6, 2026

Type of visit: Case Management - Other

On 06/25/2026, Program Analyst (PA) Lovina Aquino and Financial Analyst (FA) George Rizk arrived at the facility and met with Executive Director (ED) Harold Ermshar and Administrator (Admin) Terence Tumbale to complete the required triennial visit for Tamalpais, a Continuing Care Retirement Community (CCRC). Prior to the visit, the PA and FA reviewed documentation requested from and provided by the Admin to ensure that the provider is operating the CCRC in compliance with the statutes and is performing the services specified in its continuing care contracts. During today’s visit, the PA, FA, ED and Admin discussed the documentation received prior to the visit and toured the CCRC to ensure that all required postings and documents were accessible to residents and visitors. This includes the Certificate of Authority, which remains valid and is properly displayed by the front desk. CCCB staff also toured the community, observing the assisted living, independent living and skilled nursing unit. During the tour, CCCB staff verified that the required postings and meetings, as outlined in H&SC 1771.7 and 1771.8, are in place and compliant. As a result of today’s visit, no compliance issues pursuant to the Continuing Care Contract Statutes were cited. CCCB staff will follow up with a thank you letter, and summary provided to the ED within 7 days of the visit. An exit interview was conducted with the ED and Admin. Due to connectivity issues, CCCB staff completed the LIC 809 upon return to HQ and emailed the ED for signature.the state’s words, verbatim · CDSS document, Jun 25, 2026

Type of visit: Required - 1 Year

At approximately 10:00 AM, Licensing Program Analyst (LPA) Julie Florio arrived unannounced to conduct a required 1-year annual inspection and met with Terrence Tumbale, Administrator. Facility is an Continuing Care Residential Community (CCRC) with 279 residents in care, 34 of whom reside in the assisted living and memory care units. Community has a Hospice waiver for 15. At approximately 12:00 PM, LPA initiated a tour of the facility with Administrator and observed the following: Facility is an 11 story building with evacuation chairs placed on the second floor of each stairwell. Facility was a comfortable temperature, and passageways were free from obstructions. Water temperature in clients' bathrooms measured within the allowable range of 105 to 120 degrees F per Title 22 regulations. LPA observed a supply of paper products available to clients. Closets containing cleaning supplies and other items that could pose a risk were locked. The community has at least two days of perishable food and one week of non-perishable foods, as well as an emergency water supply. Medications were centrally stored and locked. There are several covered seating areas and outdoor space for activities throughout the community. LPA observed an activity schedule and computers with internet available for resident use. The community's fire extinguishers were observed charged and were last serviced 05/2026. Sprinklers and Smoke and Carbon Monoxide detectors were last inspected by the a third party fire and security company 04/2025. Facility conducts monthly emergency/disaster drills with the last one conducted 05/2026. Facility has a supply of PPE, emergency supplies, flashlights and a first aid kits throughout the community. Facility has at least three backup generators for emergency preparedness. Continued on LIC809-C... Continued from LIC809... LPA will return at a later date to complete staff, resident and medication file review. LPA may issue citations at the time. No Deficiencies are cited during inspection. Exit interview conducted with Administrator whose signature on form confirms receipt.the state’s words, verbatim · CDSS document, Jun 15, 2026

Type of visit: Case Management - Other

On April 16, 2026, a meet and greet was conducted at Tamalpais, a continuing care retirement community, to provide an opportunity for introductions and general discussion. The meeting included Alycia Rayner, Assistant Branch Chief, and Jennifer Houston, CCCB Manager. Paul Friesen, Executive Director, and Terence Tumbale, Administrator were present. A tour of the facility was also conducted. The purpose of this meet and greet was solely to establish communication and rapport. The meeting was not conducted for compliance or regulatory review purposes, and no issues were identified during the visit. No further action is necessary. This form was emailed following the visit due to connectivity issues and was subsequently signed by the Executive Director.the state’s words, verbatim · CDSS document, Apr 16, 2026

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Shannan Hansen arrived at 8:30AM to complete an unannounced continuation of annual inspection and met with Terence Tumbale, Administrator. There is a total of 230 residents. At approximately 8:45am LPA and Administrator conducted short inspection of facility on the 11th, 10th, & 9th, floors where renovation/replacement of ceilings, lighting, and carpets of common areas are in progress. This renovation/replacement is scheduled on all floors of the building with schedules posted at each elevator floor. At approximately 9:40am LPA conducted file review of 6 residents and 7 staff records as well, reviewed centrally stored medication records to complete this annual inspection. LPA conducted a review of six resident files and learned that all residents have an updated re-appraisals/needs & care plans and updated physician’s assessments (LIC 602A). At approximately 11:00 am on 6/12/2025 LPA conducted a review of seven staff files and learned that all facility staff present and a sample of other individuals who require caregiver background checks have received criminal record clearances or exemptions. Direct care staff annual training requirements are current and LPA was presented with proof of CPR & 1st Aid certification for staff positions requiring certification, of files reviewed. LPA discussed new dementia regulations with Administrator and Victoria Mozaffari-Yazdi, Assisted Living Nurse Manager. Continue on LIC809-C Continued from LIC809 No citations observed or given during this years inspection. LPA Hansen is requesting facility to update and submit the following documents by 6/30/2024 to CCL: LIC 308 Designation of Facility Responsibility (if changes) LIC 610 Emergency Disaster Plan (if changes) Copy of Administrator Certificate Proof of Liability Insurancethe state’s words, verbatim · CDSS document, Jun 12, 2025

Type of visit: Required - 1 Year

During today’s inspection there is a total of 16 assisted living, 24 memory care residents, and 228 independent living residents. There are five residents currently on Hospice and nine have a dementia diagnosis. LPA toured the facility on 6/10/2025 at 11:25 AM with administrator, Terence Tumbale & Victoria Mozaffari-Yazdi, Assisted Living Nurse Manager; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on 2/20/2025. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers (checked 3/27/2025) are inspected, and inspection records are current. Central Marin Fire inspection conducted on 9/12/2024. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Disaster drills are conducted quarterly / on different shifts with the last being a fire drill 5/7/2025. Hot water temperature measured between 105.6 degrees F and 120 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 13 of 13 assisted living, independent living, and memory care resident’s bathrooms while touring facility on 6/10/2025 at 12:30 PM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator/freezers and parking garage walk in refrigerator/freezers were properly stored as per regulations at the time of the visit. LPA toured the kitchen area on 6/10/2025 at 12:45 PM and learned that there are provisions made for individuals/residents with special dietary needs overseen by a dietitian and logs kept out for staff to follow. Continue on LIC809-C Continue from LIC809 Facility kitchen has a binder with resident’s names and their needs. Food is available for residents any time of the day. Menus are located at the entrance of the main dining room & the entrance of both east & west dining rooms on the second floor. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. At 1:30PM LPA initiated a file review of 10 resident files and 10 personnel files but was unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Jun 10, 2025

Type of visit: Case Management - Incident

Licensing Program Analyst (LPA) Shannan Hansen arrived unannounced to conduct a Case Management Inspection and met with Administrator Terence Tumbale. The purpose of this case management inspection is to follow up on an SOC 341 submitted to Community Care Licensing (CCL). On 5/27/2025 CCL received an SOC341 from facility reporting financial abuse noticed on 5/23/2025. During today’s inspection LPA conducted interviews and obtained records. LPA will review information, conduct additional interviews and follow up with facility. No citation issued during today’s visit.the state’s words, verbatim · CDSS document, Jun 3, 2025

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management regarding a self-reported medication error. LPA met with Administrator, Terence Tumbale. LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 8/28/2024 of a medication error. The error occurred during AM shift medication pass on 8/23/2024 while med tech was dispensing medication. Medication technician provided resident (R1) 2 milligrams of hydromorphone instead of doctors prescribing order of 1 milligram due to transcription error, Regulation 87465(a)(4). (See LIC809-D). Hospice & family contacted. R1 was monitored with no sign of adverse reaction. LPA obtained internal investigation, EMAR & care notes. LPA was also provided medication training documents for Med Tech as Nurse no longer with the community. *******Total Civil Penalties issued today in the amount of $250.00 A $250.00 civil penalty is being issued for 2nd citation in less than 12 months for the same violation 87465(a)(4). Previous citation 11/9/2023. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Sep 26, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Sep 27, 2024

87465 Incidental Medical and Dental Care(a):(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by: Based on document review and interview with Administrator, Licensee did not comply with the section cited above when R1 did not receive medication as prescribed. This poses an immediate health and safety risk to residents in care.the state’s words, verbatim · CDSS document, Sep 26, 2024

Plan of correction: Facility has provided in service re-Medication Training. POC cleared at visit.

Type of visit: Case Management - Other

Licensing Program Analyst (LPA) Hansen conducted an unannounced case management inspection and met with Terence Tumbale, Administrator. LPA conducted a walk through of facility at 9:00am, made observations and obtained additional information regarding the transitioning of the Skilled Nursing Facility (SNF) beds to Assisted Living (AL) in Residential Care Facility for the Elderly (RCFE). Administrator will be submitting additional requested documentation. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, Aug 6, 2024

Type of visit: Case Management - Annual Continuation

Licensing Program Analyst (LPA) Shannan Hansen arrived at 10:00 AM to complete an unannounced continuation of annual inspection and met with Paul Freisen, Executive Director. There is a total of 214 residents. LPA initiated a file review of 5 staff records and reviewed centrally stored medication records to complete this annual inspection. During staff file review at approximately 10:30 AM it was revealed facility had not requested a clearance transfer for staff (S1) who had worked at facility since 1/9/2024, LPA contacted CCL RO that confirmed (see LIC 809-D & LIC421 BG for ICP). Staff (S1 & S2) did not have required current First Aid training/certificate (see LIC809-D). **Civil Penalty assessed in the amount of $500.00. LPA Hansen is requesting facility to update and submit the following documents by 6/30/2024 to CCL: LIC 308 Designation of Facility Responsibility LIC 500 Personnel Record LIC 610 Emergency Disaster Plan (if changes) LIC 9020 Register of Facility Resident’s Copy of Administrator Certificate Proof of Liability Insurance Continue on LIC809-C Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights provided..the state’s words, verbatim · CDSS document, Jun 5, 2024

Type of visit: Required - 1 Year

License Program Analyst (LPA) Hansen arrived unannounced to conduct a required annual inspection of facility and was welcomed by front desk. LPA met with Administrator Terence Tumbale for the visit. There is a total of 26 assisted living & memory care residents, and 203 independent living residents. There are two residents currently on Hospice & 8 residents have a dementia diagnosis. The facility is an eleven story CCRC with independent living and assisted living setting licensed by Community Care Licensing (CCL) on all floors. The assisted living and Memory Care units are on the second floor. The facility also has a skilled nursing setting that is not licensed by CCL. LPA toured the facility on 5/16/2024 at 9:00 AM with administrator, Terence Tumbale; facility was found to be clean and at a comfortable temperature with all exits free from obstruction. Fire Extinguishers were found to be last charged on 3/6/2024 at the time of the visit. Facility smoke detectors are hard wired and sound directly to the fire station. Smoke detectors and fire sprinklers are inspected, and inspection records are current. There are emergency lights in many of the fixtures in the common areas of the facility that come on should a power outage occur. Hot water temperature measured between 107 degrees F and 118.4 degrees F within Title 22 acceptable regulation of 105 to 120 degrees F in 13 of 13 assisted living, independent living, and memory care resident’s bathrooms while touring facility on 5/16/2024 at 10:30 AM. There was a sufficient supply of both perishable and nonperishable foods as required by Title 22 Regulations. Food stored in the kitchen refrigerator were properly stored as per regulations at the time of the visit. LPA toured the kitchen area on 5/16/2024 at 11:15 AM with administrator Terence and learned that there are provisions made for individuals/residents with special dietary needs. Continue on LIC809-C Facility kitchen has a binder with resident’s names and their needs. Food is available for residents any time of the day. There is a daily activity schedule for residents. Toxins are stored in a locked housekeeping room. There was a supply of cleaners, hygiene products and paper products available for residents. A sample tour of resident’s bedrooms was conducted, and bedrooms inspected have lighting & appropriate furnishing. Facility to ensure that approved Admissions Agreements are always posted and/or accessible to public view in the facility as per Title 22 Regulations # 87507 (e)(2) Admissions Agreement “The licensee shall conspicuously post in a location accessible to public view in the facility a complete copy of the approved admission agreement, modifications and attachments, or notice of their availability from the facility.” At 12:30 MP LPA initiated a file review of five resident files and five personnel files but was unable to complete. LPA was also unable to review medication and will return at a later date to complete annual inspection. No deficiencies cited during today’s inspection.the state’s words, verbatim · CDSS document, May 16, 2024

Type of visit: Case Management - Deficiencies

Licensing Program Analyst (LPA) Hansen arrived unannounced at facility for the purpose of conducting a Case Management regarding a medication error. LPA met with Executive Director Paul Friesen and Director of Nursing Heidi Rieser RN. LPA is following up regarding a self-reported Incident Report received by Community Care Licensing (CCL) on 11/13/2023 of a medication error. The error occurred on the evening of 11/09/2023 while employee was dispensing medication. Med tech inadvertently gave resident (R1) another resident’s medications during medication passing Regulation 87465(a)(4). (See LIC809-D). Poison control contacted and confirmed to facility, the medications given are not of great concern for adverse reactions. R1 monitored with no adverse reactions. Prescribing physician and responsible party was notified of medication error. Review of on-line training for medication administration,was provided to Med tech. In service training to be conducted 11/30/2023.. LPA was provided medication training documents. Appeal of Rights Given. The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12 month period may result in civil penalties. Exit interview conducted and appeal of rights providedthe state’s words, verbatim · CDSS document, Nov 30, 2023

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87465(a)(4) · Plan of correction due date: Dec 1, 2023

87465(a)(4) Incidental Medical and Dental Care. 87465 Incidental Medical and Dental Care:(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by: Based on self-reported incident report and interview with Executive Director Paul Friesen, , Med Tech administered another resident’s medication to resident (R1) in care. Facility did not comply with the section cited above and did not administer medication to Resident as prescribed by their physician. This is an immediate health, safety and personal rights risk to residents in care.the state’s words, verbatim · CDSS document, Nov 30, 2023

Plan of correction: Facility provided Medication online Training with certificate & MAR. Due to the holiday In service has not been provided as of yet, is scheduled for today 11/30/2023 POC to be cleared when CCL is provided signed, dated in-service training & Internal Investigation.

Allegation investigated: Provider failed to notify residents and post a summary of the plans and application as required by Health and Safety Code Section 1779(e)

Complainant alleges that the Provider’s SNF Closure Application, resulted in violation of Health and Safety Code Section 1779(e) which states that, “Within 10 days of submitting an application for a certificate of authority pursuant to paragraph (3), (4), (7), or (8) of subdivision (a), the provider shall notify residents of the provider's existing community or communities of its application… A summary of the plans and application shall be posted in a prominent location in the continuing care retirement community so as to be accessible to all residents and the general public, indicating in the summary where the full plans and application may be inspected in the continuing care retirement community..” because provider failed to provide notification to residents nor posted a summary of the plans and the application in a prominent location in the community, within 10 days of the application. The Department’s investigation determined that the Department received notification in writing on June 5, 2023, of The Tamalpais’s intention and plan to convert its skilled nursing facility to assisted living and memory care; however, this application/notification was provided under HSC 1789. On September 5, 2023, the Department received an abbreviated application from The Tamalpais to delicense some of its skilled nursing facility (SNF) beds to be converted to RCFE beds. On September 12, 2023, provider sent out notification to Tamalpais residents and Resident Council with notification that the application has been filed, the notification also included the location at the community where the application, summary and plans were posted in compliance with HSC 1779(e); therefore, the Department finds the allegation “unsubstantiated”. LIC9099 delivered telephonically (Jennifer Walden, Allison Nakatomi and Paul Friesen), emailed, and signed copied emailed Unsubstantiatedthe state’s words, verbatim · CDSS document, Oct 9, 2023 · control 21-AS-20230831165745