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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200874
Report Date: 11/19/2021
Date Signed: 11/19/2021 01:52:14 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:
11/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:09 PM
MET WITH:Agustin Samaniego, Executive DirectorTIME COMPLETED:
02:10 PM
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On 11/19/2021 starting at 12:09 PM, Licensing Program Analyst (LPA) C. Lin arrived unannounced to conduct Infection Control Inspection. LPA met with Agustin Samaniego, Executive Director (ED) and explained the purpose of the visit.

Upon entry, LPA’s temperature was checked and completed Covid-19 questionnaire at Accushield, LPA toured facility including but not limited to front entrance, screening station, hand washing stations, bedrooms, bathrooms, kitchen, and common areas. There is one central entry point for universal screening for staff, residents, and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Facility staff were observed to be wearing proper PPE.

Facility has a sufficient 2-day perishable and one-week non-perishable food supply. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. Facility has Mitigation Plan, Emergency Disaster Plan, and maintains record of routine screening for residents, staff, and visitors.

No deficiency cited during visit. Exit interview conducted 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: 11/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2021
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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