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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200708
Report Date: 10/20/2022
Date Signed: 10/20/2022 05:05:22 PM

Substantiated


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
11/30/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20201130153751
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:
10/20/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Chelsea Espinoza, Associate Executive DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not prevent the spread of illness
INVESTIGATION FINDINGS:
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On 10/20/2022 at 12:55PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegation above. LPAs met with Associate Executive Director, Chelsea Espinoza.

During the course of investigation, LPA interviewed 12 staff, complainant, and witness. LPAs reviewed and obtained staff schedule, management holiday schedule, and HAI (Healthcare Associated Infections Program) report.

Interview with staff indicated that facility had sufficient PPEs for staff to use during COVID-19 outbreak in 2020 and followed prevention protocols. After reviewing HAI report, it was identified that facility did not clean and disinfect according to required contact time. (Continue on LIC9099C...)
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 15-AS-20201130153751
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: WATERMARK AT ROSEWOOD GARDENS, THE
FACILITY NUMBER: 019200708
VISIT DATE: 10/20/2022
NARRATIVE
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Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

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

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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
11/30/2020 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20201130153751

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:
10/20/2022
UNANNOUNCEDTIME BEGAN:
12:55 PM
MET WITH:Chelsea Espinoza, Associate Executive DirectorTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Facility does not have sufficient staffing to meet resident needs
Facility does not have sufficient management on site to ensure daily operations
INVESTIGATION FINDINGS:
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On 10/20/2022 at 12:55PM, Licensing Program Analysts (LPAs) G. Luk and K. Nguyen arrived unannounced to conduct a complaint investigation and deliver findings in regards to the allegations above. LPAs met with Associate Executive Director, Chelsea Espinoza.

During the course of investigation, LPA interviewed 12 staff, complainant, and witness. LPAs reviewed and obtained staff schedule and management holiday schedule.

Interview with staff indicated there were sufficient staffing because facility had caregivers from staffing agencies to assist during the facility's outbreak. Staff stated that there was management present working at the facility during the outbreak. Holiday schedule had management working throughout the holidays of 2020.
(Continue on LIC9099C...)
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20201130153751
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: WATERMARK AT ROSEWOOD GARDENS, THE
FACILITY NUMBER: 019200708
VISIT DATE: 10/20/2022
NARRATIVE
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Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegations are UNSUBSTANTIATED.

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

DATE: 10/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20201130153751
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: WATERMARK AT ROSEWOOD GARDENS, THE
FACILITY NUMBER: 019200708
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/07/2022
Section Cited
CCR
87470(a)(2)
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Infection Control Requirements. Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions... This requirement is not met as evidence by:
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Facility has agreed to re-train staff on cleaning & disinfectant procedures. Facility will submit staff sign-in sheet and training materials to CCLD by POC date.
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Based on investigation, licensee did not comply with the section cited above by not following required contact time which poses a potential health and safety risk to the persons 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: 10/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5