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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200874
Report Date: 06/24/2021
Date Signed: 06/24/2021 03:31:43 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
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, THEFACILITY NUMBER:
019200874
ADMINISTRATOR:KEVIN BOOTHFACILITY TYPE:
740
ADDRESS:1440 40TH STREETTELEPHONE:
(510) 594-8800
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY:175CENSUS: 78DATE:
06/24/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Keyanna Smith, HR DirectorTIME COMPLETED:
02:47 PM
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On 06/24/21 at 2PM, Licensing Program Analyst (LPA) Daisy Panlilio conducted a Health and Safety check as a result of the department receiving a priority 2 complaint. LPA explained the reason for the visit with the HR Director and the Regional Director.

During the health and safety check, LPA observed 14 staff wearing face masks. A universal entry station with routine COVID-19 symptom screening was observed in the front lobby. All staff, visitors and residents are required to electronically sign in, answer COVID-19 screening questions and complete the digital temperature scan. LPA toured facility with regional director, including but not limited to bedrooms, kitchen, bathroom, and common areas. Six memory care residents were observed engaged in reading activities in the recreation room assisted by 3 staff wearing face masks in the memory care unit on the 2nd floor. Other 5 residents in assisted living on the 3rd floor were observed relaxing inside their bedrooms. Residents in care appear to be safe and there are no imminent health/safety concerns on today's date.

No deficiencies cited during the health and safety check. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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