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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200874
Report Date: 09/11/2023
Date Signed: 09/11/2023 04:13:36 PM


Document Has Been Signed on 09/11/2023 04:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:WATERMARK BY THE BAY, THEFACILITY NUMBER:
019200874
ADMINISTRATOR:HALL, STEPHANIE JFACILITY TYPE:
740
ADDRESS:1440 40TH STREETTELEPHONE:
(510) 594-8800
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY:175CENSUS: 78DATE:
09/11/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:40 PM
MET WITH:Stephanie Hall, Executive DirectorTIME COMPLETED:
04:30 PM
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On 09/11/2023 at Licensing Program Analyst (LPA) L. Alexander conducted an unannounced Case Management visit regarding an incident that was reported to CCLD on 09/08/2023. LPA met with Executive Director, Stephanie Hall, and explained the purpose of the visit.

Stephanie had copies of pertinent documents relevant to this incident. Stephanie says that there wasn't any witnesses to this incident. Stephanie will
Stephanie stated that the suspect was recently hired at Elegance at Berkeley, 2100 San Pablo Ave, Berkeley, CA. Per Stephanie, supposedly the suspect is working as a private caregiver in general.

LPA L. Alexander collected documents pertinent to the incident report.

Documents received:

Suspect's Personnel File
Emails from victim's daughter
Emeryville Police Dept Report# 2309-0449

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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