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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200708
Report Date: 09/04/2020
Date Signed: 09/04/2020 03:13:47 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: 80DATE:
09/04/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Sanjay Kabadi, Executive DirectorTIME COMPLETED:
03:00 PM
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On 9/4/2020 at 2:00PM, Licensing Program Analyst (LPA) G. Luk conducted a Case Management Tele-visit regarding an incident report/death report via FaceTime due to shelter in place order directed by the Governor. LPA spoke to Executive Director, Sanjay Kabadi.

Based on the incident report/death report received on 9/2/2020, resident (R1) was found unresponsive by a caregiver. Med Tech started CPR while on the phone with Paramedics. R1 had a DNR order and compressions were stopped. Paramedics pronounced death at 8:15AM. Family was contacted.

Based on interview with S1 and S2, R1 was found unresponsive by a caregiver. Caregiver notified S2 who started CPR and called 911. While on the phone with paramedics, S2 was instructed to bring R1 to a flat surface for CPR. S2 reviewed R1's medical records and found that R1 had a DNR order. CPR was stopped. Paramedics arrived 5-10 minutes after and pronounced death. R1's family were notified.

LPA reviewed R1's physician's report which revealed that R1 was diagnosed with CHF.

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: 09/04/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2020
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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