011440777-8-27-2020-15-AS-KHOS-BTWLSM-20200929090059

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011440777
Report Date: 08/27/2020
Date Signed: 08/27/2020 03:06:23 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/10/2020 and conducted by Evaluator Celia Phomphachanh

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200610111847

FACILITY NAME:	WATERS EDGE LODGE		FACILITY NUMBER:	011440777
ADMINISTRATOR:	ENRIQUE RAMOS		FACILITY TYPE:	740
ADDRESS:	801 ISLAND DRIVE		TELEPHONE:	(510) 748-4300
CITY:	ALAMEDA	STATE: CA	ZIP CODE:	94502
CAPACITY:	120	CENSUS: 69	DATE:	08/27/2020
		UNANNOUNCED	TIME BEGAN:	02:10 PM
MET WITH:	Enrique Ramos, Administrator		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Unlocked Medications.

INVESTIGATION FINDINGS:

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On Thursday, August 27, 2020 at 2:10 PM, Licensing Program Analyst (LPA) contacted facility to conduct tele-visit and deliver findings to the above allegation. LPA spoke with Enrique Ramos, Administrator via facetime. LPA explained the reason of the call. Due to the Executive Order Shelter in Place set forth by the Governor on March 18, 2020, LPA was not able to conduct in person visit.

During the course of the investigation, LPA conducted tele-visit, interviewed staff, and reviewed records. When LPA interviewed Reporting Party (RP), RP stated first floor apartments 100, 101, 103, 111, and 115 had unlocked medications in the apartments. When LPA interviewed S1, S1 stated that residents have locked drawers for medications in their room. S1 stated if residents have medications in their room, they are able to manage their own medications and have the key to the drawers. When LPA reviewed records, LPA confirmed R1, R2, R3, R4, and R5 are able to manage and administer their own medications. R6 is not able to manage own medications, however, the facility assists with medications for R2, R3, R4, and R6 where their medications are centrally stored.

Continuation on LIC 9099C, Complaint Investigation Page 1 of 2.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020

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 2

Control Number 15-AS-20200610111847

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERS EDGE LODGE	FACILITY NUMBER: 011440777
	VISIT DATE: 08/27/2020

NARRATIVE

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Continuation Complaint Investigation, Page 2 of 2

LPA observed no one residing in Apartment 100. Apartment 101, 103, 111, and 115 all have locked drawers for medications to be stored if needed. During tele-visit, LPA did not find any medications in the drawers in Apartment 101, 103, 111 and 115.

Based on the interviews conducted and records reviewed, LPA found this allegation to be UNSUBSTANTIATED. 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.

Exit interview conducted with Administrator, Enrique Ramos. Copy of report sent via PDF email.

SUPERVISOR'S NAME: Julio Montes	TELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Celia Phomphachanh	TELEPHONE: (510)286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/27/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/27/2020

LIC9099 (FAS) - (06/04)

Page: 2 of 2