019200874-4-12-2024-15-AS-KHOS-D4MJ4M-20240424064322

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 04/12/2024
Date Signed: 04/12/2024 12:22:52 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
01/26/2024 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20240126074307

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: 78	DATE:	04/12/2024
		UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Stephanie Hall,		TIME COMPLETED:	12:35 PM

ALLEGATION(S):

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Insufficient staffing resulting in resident falls
Residents are being left in soiled clothing and undergarments
Residents are being mishandled
Residents developing bedsores while in care

INVESTIGATION FINDINGS:

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On 4/12/2024 at 10:00AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver the finding on the above allegations. LPA explained the purpose of the visit to Administrator, Stephanie Hall.

On the allegation insufficient staff resulting in resident falls. LPA observed staffing schedule for 11/1/2023-12/21/2023. Facility had sufficient staffing for all shifts, including caregivers, med techs and kitchen crew.

On the allegation Residents are being left in soiled clothing and undergarments. LPA toured the facility with ED and observed that residents were in clean unsoiled clothing. S1 was asked what staff do when they observed residents in solid clothing S1 said the staff clean them up and put them in new clothing.

Continued on LIC 9099C....

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

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-20240126074307

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: 04/12/2024

NARRATIVE

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...Continued from LIC9099
On the allegation Residents are being mishandled. Interviews with staff and residents indicated that staff does not mishandle residents while in care. Staff or residents have not seen any staff mishandle residents.

On the allegation Residents developing bedsores while in care. LPA was given a list of all of the residents who are bedridden and a list of residents who have bedsores. S1 stated that all of the residents with bedsores are bedridden and on Hospice.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegations may have happened or are valid, there are not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-Czuleger	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 04/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024

LIC9099 (FAS) - (06/04)

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