019200874-8-10-2023-15-AS-KHOS-CURRDL-20230816125608

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 08/10/2023
Date Signed: 08/10/2023 03:48:30 PM

Substantiated

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
07/28/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230728140351

FACILITY NAME:	WATERMARK BY THE BAY, THE		FACILITY NUMBER:	019200874
ADMINISTRATOR:	HALL, STEPHANIE J		FACILITY TYPE:	740
ADDRESS:	1440 40TH STREET		TELEPHONE:	(510) 594-8800
CITY:	EMERYVILLE	STATE: CA	ZIP CODE:	94608
CAPACITY:	175	CENSUS: 79	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Stephani Hall, Executive Director Jonai Davis - Hendricks, Manager on Duty		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff retained resident in a memory care unit without proper authorization

INVESTIGATION FINDINGS:

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On 08/10/23 at 3PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced complaint visit, met with manager on duty (MOD) and spoke with executive director (ED) on the phone who authorized MOD to act on her behalf and sign the reports. LPA explained the purpose of the visit with ED and MOD.

Allegation: Staff retained resident in a memory care unit without proper authorization
Investigation Finding: Substantiated
During investigation, staff (ED, S1)) confirmed with LPA that conserved resident (R1) was temporarily moved on 07/18/23 at 18:04 hours from her assisted living unit located on the fifth floor to a secured memory care unit on the second floor due to safety concerns (increased confusion & falls). LPA reviewed R1’s records and observed staff failed to obtain a court order and follow the proper legal process/authorizations required with R1’s conservatorship prior to relocating R1 from assisted living to memory care. Based on interviews and record reviews which were conducted, the preponderance of evidence standard has been met and the above allegation(s) that staff retained resident in a memory care unit without proper authorization was found to be substantiated.
Deficiency is cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. Appeal rights and a copy of this report provided.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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-20230728140351

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 09/08/2023 Section Cited CCR 87468.2(a)(16)	1 2 3 4 5 6 7	Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (16) written notice of any room changes at least 30 days in advance unless a room change is agreed to by the resident, required to fill a vacant bed, or necessary due to an emergency.	1 2 3 4 5 6 7	By POC due date, ED agreed to complete and submit to CCL in-service staff retraining certifications on full understanding of residents’ conservatorship requirements and will comply with all legal provisions of conservatorship at least 30 days prior to relocating any conserved resident. ED also agreed to complete and submit to CCL in-service staff retraining on residents’ personal rights in compliance with Title 22 Section 87468.2
	8 9 10 11 12 13 14	This requirement was not met as evidenced by staff relocating conserved resident from assisted living to memory care prior to securing proper authorization from conservator which posed a potential health & safety risk to resident in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 4

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
07/28/2023 and conducted by Evaluator Daisy Panlilio

COMPLAINT CONTROL NUMBER: 15-AS-20230728140351

FACILITY NAME:	WATERMARK BY THE BAY, THE		FACILITY NUMBER:	019200874
ADMINISTRATOR:	HALL, STEPHANIE J		FACILITY TYPE:	740
ADDRESS:	1440 40TH STREET		TELEPHONE:	(510) 594-8800
CITY:	EMERYVILLE	STATE: CA	ZIP CODE:	94608
CAPACITY:	175	CENSUS: 79	DATE:	08/10/2023
		UNANNOUNCED	TIME BEGAN:	03:17 PM
MET WITH:	Stephani Hall, Executive Director J Davis - Hendricks, Manager on Duty		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Resident was not provided adequate living conditions while in care

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

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

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 15-AS-20230728140351

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: 08/10/2023

NARRATIVE

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LPA toured the facility’s secured memory care unit on the second floor and observed the following: secured entrance with code or key fob activation required for access, thermostat reading at 73 deg F in common carpeted hallways, large TV room with carpeted floors, 30 plus chairs for residents to use, 2 activity rooms with arts/crafts and storage cubes, inside garden with patio umbrellas, tables/ chairs, dining room with tables/chairs and big windows with sliders.

The private room temporarily used by R1 in memory care was observed to be unlocked, have hard wood floors with a private full bath (toilet and shower stall with several handicap grab bars on walls, shower chair & towel holders), 2 wooden armoires, big window with sliders, independent air conditioner attached to the left upper wall with an accessible remote controller and kitchen sink with storage cabinets. ED stated rooms come unfurnished and residents bring their own furniture to use in their apartments.

LPA observed the facility to be clean, odor free and in good repair. LPA observed 8 staff on the floor assisting 14 memory care residents who were comfortable in their surroundings during visit. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation that resident was not provided adequate living conditions while in care is unsubstantiated.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy Panlilio	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 08/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2023

LIC9099 (FAS) - (06/04)

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