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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200708
Report Date: 11/29/2022
Date Signed: 11/29/2022 04:52:04 PM

Unsubstantiated


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
06/22/2021 and conducted by Evaluator Grace Luk
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20210622124047
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: 52DATE:
11/29/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Chelsea Espinoza, Associate Executive DirectorTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Staff do not prevent a resident from wandering while in care
Resident sustained multiple falls while in care
Resident sustained multiple unexplained injuries while in care
INVESTIGATION FINDINGS:
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On 11/29/2022 at 10:40AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct complaint investigation and deliver findings for the allegations above. LPA met with Associate Executive Director, Chelsea Espinoza.

During the course of investigation, LPA interviewed 8 staff and witness. LPA reviewed and obtained staff schedule, physician's report, care plans, emergency information, incident reports, and correspondence with doctor.

Staff do not prevent a resident from wandering while in care
Interview with staff and witness revealed that R1 did not wander outside of facility and facility staff was able to follow or redirect R1 back to memory care unit. Staff stated that R1 was monitored frequently to prevent AWOLs. Incident reports indicated that R1 did not leave the facility and staff was able to redirect R1 back inside. There were no additional information provided from complainant regarding R1's AWOLs. (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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
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 2
Control Number 15-AS-20210622124047
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: 11/29/2022
NARRATIVE
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Resident sustained multiple falls while in care
Interview staff and witness revealed that R1 does not have a history of falls. Witness stated that R1 have loss balance and fallen, but staff would encourage R1 to use the walker to prevent falls. LPA reviewed fax correspondence with doctor and observed that staff notified doctor when R1 had a fall.

Resident sustained multiple unexplained injuries while in care
Interview with staff revealed R1 had bruises and was unaware how R1 sustained injuries. Staff stated that R1 often hit the doors and walls to wander out of facility. LPA reviewed fax correspondence with doctor and observed that staff notified doctor when injuries were discovered on R1. R1's family was notified of R1's injuries.

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: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2