019200874-8-4-2020-15-AS-HHUL-BTSSXH-20200925141556

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 08/04/2020
Date Signed: 08/04/2020 03:04:35 PM

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
02/19/2020 and conducted by Evaluator Laura Hall

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200219152426

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: 78	DATE:	08/04/2020
		UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Kevin Booth, Executive Director		TIME COMPLETED:	03:05 PM

ALLEGATION(S):

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Lack of supervision

INVESTIGATION FINDINGS:

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On 08/04/2020 at 02:35pm, Licensing Program Analyst (LPA), L. Hall had an unannounced tele-visit via facetime to deliver the findings on the allegation that “resident had a lack of supervision while in care of the facility”. LPA spoke with Kevin Booth, Executive Director and explained the reason for the tele-visit.

During the course of the investigation, LPA conducted interviews with staff, a resident, and collected and reviewed documentation. Based on interviews conducted and review of documentation in relation to R2, it was determined that R2 has a 1-on-1 personal caregiver from 9:00am – 11:00pm and the facility staff to assist R2 24 hours a day. During interviews with staff and the personal caregiver it was disclosed that R2 does not allow personal caregiver into R2’s apartment but does allow facility staff to come in on occasion to assist with ADLs.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

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-20200219152426

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: 08/04/2020

NARRATIVE

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Continued from LIC9099.

Based upon the information obtained during investigation. The above allegation is unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred.

Exit interview conducted over the phone with Kevin Booth, Executive Director. A copy of report will be emailed.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 08/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/04/2020

LIC9099 (FAS) - (06/04)

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