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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440777
Report Date: 12/17/2025
Date Signed: 12/17/2025 05:03:34 PM

Document Has Been Signed on 12/17/2025 05:03 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WATERS EDGE LODGEFACILITY NUMBER:
011440777
ADMINISTRATOR/
DIRECTOR:		LAGASCA-CRUZ, MARIE ANN NFACILITY TYPE:
740
ADDRESS:801 ISLAND DRIVETELEPHONE:
(510) 748-4300
CITY:ALAMEDASTATE: CAZIP CODE:
94502
CAPACITY: 120CENSUS: 69DATE:
12/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Stephen Zimmerman, Administrator TIME VISIT/
INSPECTION COMPLETED:
05:25 PM
NARRATIVE
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On 12/17/2025 at 9:30 AM, Licensing Program Analysts (LPAs) P. Manalo and K. Nguyen arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Stephen Zimmerman, and explained the purpose of the visit.

LPA toured the facility inside and out including but not limited to 6 residents' apartments, bathrooms, activity rooms, kitchen, and courtyards. LPA observe lighting in all rooms is adequate for the comfort and safety of the residents. Hallway temperature was maintained at 75 degrees F. The hot water temperature in a sample of residents shared bathroom were measured at 110.6, 110, 112, 109.8 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid shower pans. There is a minimum of one week supply of nonperishable and 2-day of perishable foods.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 08/07/2025. Emergency disaster drill was last conducted on 12/03/2025.

At 10:31 AM, LPA reviewed 7 residents records. At 11:20 AM, LPA reviewed 7 staff records and 6 of 7 have current first aid training. LPA reviewed a sample of resident’s medications.

Continue to LIC809-C...
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2025
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 12/17/2025 05:03 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/17/2025 at 04:34 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERS EDGE LODGE
FACILITY NUMBER: 011440777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations at 12:45 PM and record review, the licensee did not comply with the section cited above by having unlocked medications such as Systane eyedrops, knife, Lysol spray, etc. in R3’s room and Probiotic, Airborne, and Clean Smart Disinfectant Spray in R4’s room which poses an immediate health and safety risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
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The Administrator agrees to review residents’ physician reports and remove the items in the room. Proof of correction will be sent to CCLD by POC date.
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation at 12:24 PM, the licensee did not comply with the section cited above in having multiple bugs found in the flour, tempura flakes, and having fruit flies around the kitchen area which poses a potential safety risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
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The Administrator will call the pest company and discard the items found with bugs. Proof of correction will be sent to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


LIC809 (FAS) - (06/04)
Page: 5 of 9
Document Has Been Signed on 12/17/2025 05:03 PM - It Cannot Be Edited


Created By: Patricia Manalo On 12/17/2025 at 04:34 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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERS EDGE LODGE
FACILITY NUMBER: 011440777

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/17/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)(1)
Maintenance and Operation
(a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations at 12:53 PM, the licensee did not comply with the section cited above by having R5’s toilet covered in feces and diaper left in the bathroom sink which poses a potential safety risk to persons in care.
POC Due Date: 12/19/2025
Plan of Correction
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The Administrator agrees to clean the bathroom and send proof to CCLD by POC date.
Type B
Section Cited
CCR
87412(a)(4)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information: (4) Written verification that the employee is at least 18 years of age, including, but not necessarily limited to, a copy of his/her birth certificate or driver's license.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations and record review at 2:53 PM, the licensee did not comply with the section cited above by having S5 working at the facility under the age requirements which poses a potential safety risk to persons in care.
POC Due Date: 12/29/2025
Plan of Correction
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The Administrator will remove the staff and send an updated LIC500 to CCLD by POC date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Yvonne Flores-Larios
NAME OF LICENSING PROGRAM MANAGER:
Patricia Manalo
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/17/2025


LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERS EDGE LODGE
FACILITY NUMBER: 011440777
VISIT DATE: 12/17/2025
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Continue from LIC809...

THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING VISIT:


At 12:45 PM, LPAs observed unlocked medications such as Systane eyedrops, knife, Lysol spray, etc. in R3’s room and Probiotic, Airborne, and Clean Smart Disinfectant Spray in R4’s room.

At 12:53 PM, LPAs observed R5's bathroom toilet covered in feces and a diaper was left in the sink.

At 2:53 PM, LPAs observed that S5 is under the age requirements.

At 12:24 PM, LPAs observed multiple bugs in the flour and tempura flakes. LPAs observed fruit flies around the kitchen.

The Facility was cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted with Administrator. Appeal Rights and a copy of this report provided.
NAME OF LICENSING PROGRAM MANAGER: Yvonne Flores-Larios
NAME OF LICENSING PROGRAM ANALYST: Patricia Manalo
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2025
LIC809 (FAS) - (06/04)
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