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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 12/18/2024
Date Signed: 12/18/2024 11:50:47 AM

Substantiated


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
11/06/2024 and conducted by Evaluator Jill Clancy-Czuleger
COMPLAINT CONTROL NUMBER: 15-AS-20241106103617
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: 83DATE:
12/18/2024
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Stephanie Hall, Executive Director TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff unlawfully evicted a resident
Staff over charged a resident
INVESTIGATION FINDINGS:
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On 12/18/2024 at 11:10AM, Licensing Program Analysts (LPAs) J. Clancy-Czuleger arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director Stephanie Hall explained the purpose of the visit.

On the allegation: Staff unlawfully evicted a resident
Based on record review and interviews the facility did send R1 and R1’s POA a notice titled “Final Demand to Pay & Discharge Notice” on October 18, 2024. This notice stated “this letter services as your official 30-Day Notice” but did not include resources available to assist in identifying alternative housing and care options.
On the allegation: Staff over charged a resident
Based on records review, and interviews, in March of 2024 the facility discussed a level of care change with a family member that was not the resident’s representative and did not disclose that this care change would come with an increased rate. Both W1 and W2 stated that they did not receive any written notice of the care change or the rate change.
Continued on LIC9099-C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 15-AS-20241106103617
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: 12/18/2024
NARRATIVE
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...Continued from 9099

Based on LPAs interviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), is being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20241106103617
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/18/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/01/2025
Section Cited
HSC
1569.657(a)
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For any rate increase due to a change in the level of care ... the licensee shall provide the resident and the resident’s representative, if any, written notice of the rate increase … a detailed explanation of the additional services ... This requirement is not met as evidenced by:
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The facility agrees to submit the notice of reduced care charges that was sent to the resident/POA. The facility also agrees to review the regulations and submit a letter of self certification to CCLD by POC date.
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Based on interview and record review the licensee did not comply with the section cited above by not providing the resident and the resident’s representative, if any, written notice of the rate increase within two business days
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Type B
01/01/2025
Section Cited
CCR
87224(d)(1)(b)
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The licensee shall set forth in the notice to quit the reasons relied upon …. (1)The notice to quit shall include the following information:(B) Resources available to assist in identifying alternative housing and care options which include…This requirement is not met as evidenced by:
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 The facility agrees to review the regulations and submit a letter of self certification to CCLD by POC date.
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Based on interview and record review the licensee did not comply with the section cited above by serving R1 with an eviction notice that did not contain all items required under regulation, which poses a potential health and safety and personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Jill Clancy-CzulegerTELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3