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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200708
Report Date: 06/02/2020
Date Signed: 06/02/2020 02:25:56 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:WATERMARK AT ROSEWOOD GARDENS, THEFACILITY NUMBER:
019200708
ADMINISTRATOR:HARRISON, NANCYFACILITY TYPE:
740
ADDRESS:35 FENTON STREETTELEPHONE:
(925) 443-7200
CITY:LIVERMORESTATE: CAZIP CODE:
94550
CAPACITY:115CENSUS: 83DATE:
06/02/2020
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Dawn Schubert, Program DirectorTIME COMPLETED:
02:20 PM
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On 6/2/2020 at 2:00 PM, Licensing Program Analyst (LPA) G. Luk conducted a Case Management regarding a death report over the phone due to shelter in place order directed by the Governor. LPA spoke to Program Director, Dawn Schubert.

Based on the death report received on 6/1/2020, resident (R1) became unresponsive on 5/20/2020 and was sent to the hospital. R1 was hospitalized due to aspiration. R1 passed away at the hospital several days later.

LPA was informed that a staff noticed R1 eating soup and R1's head was leaning forward. When staff checked on R1, R1 was unresponsive and facility called 911. R1 was pale. R1's health had been declining during previous weeks. When paramedics arrived, R1 was given oxygen and taken to the hospital. R1 was not on hospice care and living in the memory care unit of the facility. R1's family notified facility that R1 had aspiration.

LPA reviewed R1's physician's report and care plan. R1 was able to feed herself and does not require assistance. LPA was informed that if R1 isn't eating, a staff would encourage and remind R1 to eat.

No deficiencies are being cited on this date.

Exit interview conducted and a copy of this report will be emailed.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/02/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2020
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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