019200874-2-15-2023-15-AS-BFOG-CQ528U-20230320171051

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 02/15/2023
Date Signed: 02/15/2023 10:30:02 AM

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
06/24/2021 and conducted by Evaluator Kelly Nguyen

COMPLAINT CONTROL NUMBER: 15-AS-20210624090925

FACILITY NAME:	WATERMARK BY THE BAY, THE		FACILITY NUMBER:	019200874
ADMINISTRATOR:	KEVIN BOOTH		FACILITY TYPE:	740
ADDRESS:	1440 40TH STREET		TELEPHONE:	(510) 594-8800
CITY:	EMERYVILLE	STATE: CA	ZIP CODE:	94608
CAPACITY:	175	CENSUS: 66	DATE:	02/15/2023
		UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Stephane Hall Executive Director		TIME COMPLETED:	10:40 AM

ALLEGATION(S):

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Facility staff caused injury to resident

INVESTIGATION FINDINGS:

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On 2/15/23 at 10:00AM, Licensing Program Analyst (LPAs) K. Nguyen and L. Francisco arrived unannounced to deliver finding for the above allegation. LPA met with Stephane Hall Executive Director and explained the purpose of the visit.

Base of record reviewed of daily note LPA observed an incident that occurred on 6/19/21 were a staff was redirecting R1 from another resident room. It was noticed S6 accidently starched R1 hand while taking the phone from R1 hand. When staff observed the starched first aid was applied. No additional information forth coming from staffs.

Base one records reviewed, 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 and a copy of this report provided to Executive Director.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Kelly Nguyen	TELEPHONE: (510) 915-8702
LICENSING EVALUATOR SIGNATURE:	DATE: 02/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/15/2023

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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