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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200708
Report Date: 06/28/2021
Date Signed: 06/28/2021 12:19:03 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: 54DATE:
06/28/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Chelsea Espinoza, Business DirectorTIME COMPLETED:
12:30 PM
NARRATIVE
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On 6/28/2021 at 11:30AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a case management visit. LPA met with Business Director, Chelsea Espinoza. While LPA was at the facility conducting another visit, the following deficiency was observed.

During visit, LPA tested delayed egress doors in Memory Care Unit. LPA observed that one of the delayed egress doors in the Memory Care Unit opens without the 15 seconds hold. LPA tested the delayed egress doors in the presence of a staff member (S2).

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.


Exit interview conducted. A copy of this report and appeal rights were provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2021
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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, THE
FACILITY NUMBER: 019200708
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/28/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/02/2021
Section Cited

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Maintenance and Operation.
The facility shall be clean, safe, sanitary and in good repair at all times...
This requirement is not met as evidence by:
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Based on observation, licensee did not comply with the section cited above by having one inoperable delayed egress door which poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2021
LIC809 (FAS) - (06/04)
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