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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200874
Report Date: 12/13/2022
Date Signed: 12/13/2022 11:05:48 AM


Document Has Been Signed on 12/13/2022 11:05 AM - 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: 62DATE:
12/13/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:38 AM
MET WITH:Stephanie Hall, AdministratorTIME COMPLETED:
11:15 AM
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On 12/13/2022, Licensing Program Analyst (LPA) C. Lin conducted an unannounced case management health & safety check during the course of investigation. LPA met with Administrator and explained the purpose of the visit.

LPA was screened at the front entrance with routine COVID-19 symptom and temperature checks done. LPA toured the facility with ED. LPA observed facility had sufficient food supplies in the kitchen. LPA also observed extra water supplies located in the garage. LPA observed Cough/sneeze etiquette and hand washing posters were posted in common areas and bathrooms. LPA observed dining area has been expanded to give additional seating choices for residents with tables six feet apart for social distancing.

Staff was observed wearing surgical masks. Pathways and hallways were observed free of obstruction and fire hazards.

There was no imminent health/safety concerns on today's date.

Exit interview conducted with Administrator and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine LinTELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:
DATE: 12/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/13/2022
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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