019200874-5-3-2024-15-AS-HHUL-D53P7H-20240508110358

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 05/03/2024
Date Signed: 05/03/2024 12:47:45 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
02/07/2024 and conducted by Evaluator Jill Clancy-Czuleger

COMPLAINT CONTROL NUMBER: 15-AS-20240207125808

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: 82	DATE:	05/03/2024
		UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Stephanie Hall, Executive Director		TIME COMPLETED:	01:05 PM

ALLEGATION(S):

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9

A resident sustained an unexplained injury/fracture while in care.

INVESTIGATION FINDINGS:

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On 5/3/2024 at 12:30PM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA explained the purpose of the visit with Executive Director Stephanie Hall.

On the allegation facility A resident sustained an unexplained injury/fracture while in care. Based on record review and interviews the facility did observe that R1 right shoulder was swollen is leaning to the left side. 911 was called and was sent to the hospital for further evaluation where it was found that Right Proximal Humerus unspecified type fracture. R1 lives on the assisted living floor and the fall was unwitnessed.

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.

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: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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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