019200874-7-17-2020-15-AS-KHOS-BSEJE9-20200812065845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 07/17/2020
Date Signed: 07/17/2020 10:15:14 AM

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
06/09/2020 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200609092708

FACILITY NAME:	WATERMARK BY THE BAY, THE		FACILITY NUMBER:	019200874
ADMINISTRATOR:	MARTIN, CHERYL		FACILITY TYPE:	740
ADDRESS:	1440 40TH STREET		TELEPHONE:	(510) 594-8800
CITY:	EMERYVILLE	STATE: CA	ZIP CODE:	94608
CAPACITY:	175	CENSUS: 79	DATE:	07/17/2020
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Stephanie Thune-Barnes, Managing Director		TIME COMPLETED:	10:10 AM

ALLEGATION(S):

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Facility staff did not seek medical attention for the resident.

INVESTIGATION FINDINGS:

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On 7/15/2020 on 9:45am, Licensing Program Analyst (LPA) L. Francisco contacted facility to delivery finding for the above allegation via tele-visit due to shelter in place directed by the Governor. LPA conducted tele-visit via facetime with Managing Director, Stephanie Thune-Barnes.

During the course investigation, LPA obtained information, collected documents, interviewed staff and witness. Based on information obtained by reporting party, facility staff did not seek medical attention for resident. An interview with S2 revealed that resident (R1) wanted to go to the hospital after witnessing R2 being transported due to a fall that occurred on 6/6/2020. S2 stated a half hour later, a staff witnessed R1 leaned against the railings and slid down to the floor. R1 was evaluated by S2 with no apparent injury, however, R1 insisted on going to the hospital. According to S2, staff was instructed by witness (W1) not to admit R1 to the hospital, however, R1 called 911.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20200609092708

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 BY THE BAY, THE	FACILITY NUMBER: 019200874
	VISIT DATE: 07/17/2020

NARRATIVE

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When paramedics arrived, R1 was advised not to go to the hospital due to the risk of COVID-19 exposure but R1 insisted in going to the hospital. Based on information obtained, R1 had a problem walking at the hospital and was transferred to skilled nursing facility for rehab. However, based on interview with S1, facility was informed by skilled nursing facility that R1 had no issue walking. Based on interview with W1, facility is good at notifying and seeking medical attention for R1.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted an a copy of this report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/17/2020

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2020

LIC9099 (FAS) - (06/04)

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