019200874-5-15-2023-15-AS-KHOS-D3AGKW-20240312052526

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 05/15/2023
Date Signed: 05/15/2023 04:42:00 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
05/08/2023 and conducted by Evaluator James Sampair

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230508163238

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: 69	DATE:	05/15/2023
		UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Administrator Stephanie Hall		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff are not providing documentation to resident's physican concerning a reassessment evaluation.
Staff are not safeguarding resident's finances.

INVESTIGATION FINDINGS:

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On 05/15/2023 at 2:15 PM, Licensing Program Analyst (LPA) J. Sampair arrived unannounced to conduct an initial 10-day investigation regarding the above allegations. LPA explained the purpose of the visit to front desk staff and later with Executive Director (ED) Stephanie Hall.

LPA interviewed the Complainant, Witness, Administrator, Resident, and conducted a review of resident and facility records. Concerning those 2 allegations, the LPA found that:

Staff are not providing documentation to resident's physican concerning a reassessment evaluation.
There was no evidence that facility was acting in a way that interfered with a legitimate request for documentation from the Resident's physician.

Staff are not safeguarding resident's finances.
There was no evidence that the facility was not safeguarding the resident's finances.

(Continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

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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Control Number 15-AS-20230508163238

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: 05/15/2023

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32	(...Continued from LIC9099) 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. Exit interview conducted and a copy of this report provided via email.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: James Sampair	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2023

LIC9099 (FAS) - (06/04)

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