019200874-4-13-2023-15-AS-KHOS-CR7MFR-20230424093446

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 04/13/2023
Date Signed: 04/13/2023 01:29:34 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
10/08/2021 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20211008123744

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: 69	DATE:	04/13/2023
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	HALL, STEPHANIE J, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Resident is being illegally evicted.
Facility is threatening resident while in care.
Resident is being emotionally abused while in care.

INVESTIGATION FINDINGS:

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On 4/13/2023 at 1:00PM, Licensing Program Analyst (LPA) L. Ibo arrived unannounced to conduct complaint investigation for the above allegations. LPA met with Administrator, Stephanie Hall and explained the purpose of the visit.

Allegation: Illegal eviction

After reviewing eviction notice, the 30-day notice does meet requirements in regulation 87224. Based on records review and interview, R1 still lives at the facility.

Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

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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Control Number 15-AS-20211008123744

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: 04/13/2023

NARRATIVE

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Facility is threatening resident while in care.

Based on interview with staff and residents. The staff denied threatening the residents in care, staff denied hearing or witnessing any staff threatening the residents in care. Based on residents’ interview, residents denied feeling threatened by staff, residents also denied hearing any staff threatened any residents in care.

Resident is being emotionally abused while in care.

It was alleged resident (R1) is being emotionally abused while in care. Based on interview with 6 staff and 2 residents, 6 of 6 staff and 2 of 2 residents denied allegation.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited.

Exit Interview conducted and a copy of this report provided to Administrator.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/13/2023

LIC9099 (FAS) - (06/04)

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