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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 04/01/2022
Date Signed: 04/01/2022 01:24:57 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
01/25/2022 and conducted by Evaluator Catherine Lin
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20220125153756
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: 68DATE:
04/01/2022
UNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Stephanie Hall, Executive DirectorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff do not provide a safe environment for residents in care.
INVESTIGATION FINDINGS:
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On 4/1/22 at 11:25am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegation and deliver investigation findings. LPA explained the purpose of the visit with the Executive Director, Stephanie Hall.

The Department has investigated this allegation and per observations, interviews and records review, no sign of neglect was observed in the memory care unit. Staff patiently assisted residents for their physical activities and meals. The unit was observed clean, all exit doors around the unit were observed locked, residents were observed peaceful, and some residents have smiling on their face. R11’s needs and service plan dated on 2/3/22 didn’t indicate there was the needs of increasing physical therapy and 24 hours care. Staff provided what residents needed.

Continue on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
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 2
Control Number 15-AS-20220125153756
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: 04/01/2022
NARRATIVE
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Although the allegation may have happened or is valid, there is not a preponderance of evidence to provide the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

No deficiencies cited. Exit interview conducted with the Executive Director, and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:

DATE: 04/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2