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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440777
Report Date: 11/02/2022
Date Signed: 11/02/2022 03:48:50 PM


Document Has Been Signed on 11/02/2022 03:48 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WATERS EDGE LODGEFACILITY NUMBER:
011440777
ADMINISTRATOR:ENRIQUE RAMOSFACILITY TYPE:
740
ADDRESS:801 ISLAND DRIVETELEPHONE:
(510) 748-4300
CITY:ALAMEDASTATE: CAZIP CODE:
94502
CAPACITY:120CENSUS: 64DATE:
11/02/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:05 PM
MET WITH:David Ballerini, Marketing DirectorTIME COMPLETED:
04:00 PM
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On 11/2/22 at 3:05PM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving residents from Grand Lake Gardens (GLG) and check on residents. LPA met with Marketing Director and explained the purpose of the visit.

During visit, LPA obtained Waters Edge Lodge (WEL) staff schedules. Total of 3 residents from GLG are currently living in WEL. LPA met with 1 resident who just moved in today and her family member stated that she was happy.

Food, paper, PPE supplies were adequate.

Exit interview conducted with Marketing Director and copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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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