011440777-11-7-2022-15-AS-YFLS-CLAVLE-20221118153147

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011440777
Report Date: 11/07/2022
Date Signed: 11/07/2022 03:38:58 PM

Unsubstantiated

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
10/31/2022 and conducted by Evaluator Gregory Clark

COMPLAINT CONTROL NUMBER: 15-AS-20221031104835

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: 63	DATE:	11/07/2022
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	David Ballerini, Director of Marketing		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff engaging in inappropriate interaction with resident

INVESTIGATION FINDINGS:

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On 11/7/22 at 1:30 p.m. Licensing Program Analyst (LPA) Greg Clark conducted an unannounced visit to open an initial 10-day complaint investigation in regards to the allegation above. LPA met David Ballerini, Director of Marketing and Marie Lagasca-Cruz, Executive Director informed them the reason for visit.

During the course of visit LPA reviewed the staff and resident roster, R1's records including physician's report. LPA interviewed staff (S1 and S2) and resident (R1).

Interviews with staff and resident confirmed that S1 did work at the facility as the Activity Manager and that. S1 and R1 where friendly with each other at the facility. S1 did speak with S2 regarding the facilities policy regarding staff's relationship with residents.

Cont'd on 9099c

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221031104835

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: 11/07/2022

NARRATIVE

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***report continues from 9099***

S2 confirmed that she told S1 that the facility has a zero tolerance policy regarding staff and residents having relationships. S1 also confirmed this conversation.

R1 and S1 both reported that they had several lunch and diners together off site while S1 was employed at the facility.

Review of R1's physician's report revealed that there is no dementia diagnosis and R1 can leave the facility unassisted.

This agency has investigated the complaint alleging staff engaging in inappropriate interaction with resident have found that the complaint was 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, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this reported provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory Clark	TELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2022

LIC9099 (FAS) - (06/04)

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