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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200874
Report Date: 10/05/2022
Date Signed: 10/05/2022 01:37:07 PM


Document Has Been Signed on 10/05/2022 01:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



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: 58DATE:
10/05/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Stephanie Hall, AdministratorTIME COMPLETED:
01:50 PM
NARRATIVE
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On 10/5/22 at 9:10AM, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management visit as a result of receiving self-reported incident dated 09/29/22 submitted to CCLD regarding resident sustained injury while in care. LPA explained the purpose of the visit with administrator (ADM).

Upon entry, LPA went up to the 3rd floor and tested the egress door. LPA observed that the egress door alarm went off 30 seconds before opened when being pushed, and the alarm was loud enough to be heard throughout the building. ADM investigated the incident and stated that staff didn't respond timely when the alarm going off that resulted the resident in wheelchair was able to exit out to the stairway, wheeled down the stairway from the 3rd floor to the middle session where between the 3rd and 2nd floor, and injured. ADM stated that the responsible staff was suspended immediately after the incident occurred. Suspension letter from HR was provided. At a later time, ADM stated that the responsible staff was terminated as of today.

LPA observed that the subject resident's most resent physician's report (LIC602) was dated on 11/18/2019. During visit, LPA randomly reviewed 3 memory care residents' LIC602 and observed that 2 out of 3 LIC602 were not updated yearly.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC809 D. Failure to submit proofs of correction (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

A $500 immediately Civil Penalties is assessed on this day. Civil penalty determination related to serious bodily injury is pending.

Exit interview conducted with ADM. LIC809D, LIC421M, Appeal Rights, and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 10/05/2022 01:37 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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: 10/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/06/2022
Section Cited

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights:
(4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.

This requirement is not met as evidenced by…
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Based on record reviewed and interview, licensee did not comply with the section cited above. Staff didn't respond timely to egress door alarm going off when resident exited to stairway and resulted resident injury which poses an immediate health, safety risk to persons in care.
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A $500 immediately Civil Penalties is assessed
Type B
10/19/2022
Section Cited

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87705 Care of Persons with Dementia
(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment....

This requirement is not met as evidenced by…
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Based on record reviewed and interview, licensee did not comply with the section cited above. Residents with dementia didn't have updated physician's report on file which poses an potential health, safety 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: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 10/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/05/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2