019200874-4-9-2024-15-AS-KHOS-D4MNUZ-20240424104709

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 04/09/2024
Date Signed: 04/09/2024 10:51:09 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
03/13/2024 and conducted by Evaluator Luisa Fontanilla

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240313115419

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: 81	DATE:	04/09/2024
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	JoNai David-Hendricks		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff did not accord privacy to resident in care.
Staff did not ensure that resident's hygiene needs were met.
Staff did not ensure that resident was provided clean bedding.
Staff did not ensure that resident's room was maintained in a clean condition.
Staff did not ensure that resident was administered all of their medication(s).
Staff are not adequately trained.

INVESTIGATION FINDINGS:

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On this day at around 10:20 am, LPA Luisa Fontanilla arrived unannounced to deliver findings for the above allegations. LPA was met by Human Resources Director JoNai Davis-Hendricks. LPA explained to Hendricks the purpose of the visit. The Executive Director was out of the office but was contacted via telephone and authorized Hendricks to sign the report.

On 3/19/2024, LPA Luisa Fontanilla conducted an initial visit and met with Stephanie Hall, Executive Director. During the visit, LPA obtained the following records: Resident 1 (R1) Physician’s Report, Identification and Emergency Information, Medication Administration Record (MAR), and Assessment, Staff Roster and Resident Roster. LPA interviewed a total of five staff.

Based on records reviews and interviews conducted, R1 stayed at the facility on respite. Upon move in, R1 was missing one medicine. Staff 3 (S3) states R1’s son was aware of the missing medicine. LPA observed S3’s notes in R1’s MAR that R1’s son and primary doctor were notified. The MAR also indicates that R1’s son informed S3 that the medication was not available in the pharmacy.

continuation on Lic 9099C
.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

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-20240313115419

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: 04/09/2024

NARRATIVE

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While at the facility, R1 tested positive for Covid. Staff interviewed state all the care needed including but not limited to assistance with ADLs as indicated in the assessment, housekeeping/changing of sheets once a week were provided. Staff state they wore full PPEs when going inside R1’s room to make sure care is provided.

Regarding R1’s meal during isolation, staff interviewed state that dining staff would bring all of R1’s foods and leave them outside R1’s room. Then the caregivers would bring the food inside R1’s room wearing full PPEs.

In regard to the privacy allegation, LPA interviewed S3. S3 states that while waiting for one of R1’s medicines that was ordered, a package was delivered. Thinking that it was R1’s medicine, S3 states that S3 opened the package. When S3 found out that it was not the medicine, S3 went to R1 and apologized. S3 states that R1 seemed fine and appreciated everything that the staff do for R1.

LPA attempted to contact Reporting Party (RP) multiple times and left voice messages to obtain additional information and clarification regarding employee training. LPA did not get any call back from RP.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

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

No deficiencies were noted.

Exit interview was conducted with the Hendricks and a copy of this report was provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Luisa Fontanilla	TELEPHONE: (510) 286-7147
LICENSING EVALUATOR SIGNATURE:	DATE: 04/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024

LIC9099 (FAS) - (06/04)

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