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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 10/26/2020
Date Signed: 10/26/2020 11:58:51 AM

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 AT SAN RAMON, THEFACILITY NUMBER:
079200962
ADMINISTRATOR:HARRISON, NANCYFACILITY TYPE:
740
ADDRESS:12720 ALCOSTA BLVDTELEPHONE:
(925) 725-1485
CITY:SAN RAMOSSTATE: CAZIP CODE:
94583
CAPACITY:95CENSUS: 0DATE:
10/26/2020
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Nancy HarrisonTIME COMPLETED:
11:50 AM
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On 10/26/2020 at 10:00AM, Licensing Program Analyst (LPA) Roland Pitcher conducted a Tele-visit Pre-Licensing inspection via Face Time due to shelter in place directed by the Governor. LPA spoke with Executive Director, Nancy Harrison for this purpose. The building fire clearance is approved for 80 non-ambulatory and 15 bedridden residents which is a 2 level building.

During the Tele-Inspection, LPA virtually toured the building inside and outside with Harrison including but not limited to 2 model apartments in the assisted living and memory care unit, bathroom, common areas, 2 dining rooms, commercial kitchen and laundry room, activity and club room, wellness center, beauty salon, library and courtyards.

LPA observed resident bathrooms are equipped with grab bars, water temperature tested 115.3 . LPA observed sufficient lighting throughout the building. LPA observed there is a 7-day supply of non-perishable foods and non-perishable food will be purchased prior to resident move-in.

LPA observed medication room equipped with medication carts with locks, locked area for cleaning supplies and toxins. Smoke detectors are interconnected with sprinkler system. Carbon Monoxide detectors are in common areas and apartments. First aid kit complete.

Report is continued on LIC 809C
SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 AT SAN RAMON, THE
FACILITY NUMBER: 079200962
VISIT DATE: 10/26/2020
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This report will be submitted to the Central Applications Unit (CAU) and a final review of the application will be conducted. This facility is not yet licensed, and is subject to final approval by Centralized Application Unit.

Exit interview was completed with Nancy Harrison.

SUPERVISOR'S NAME: Julio MontesTELEPHONE: (510) 286-0518
LICENSING EVALUATOR NAME: Rolanda PitcherTELEPHONE: (510) 542-0253
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2020
LIC809 (FAS) - (06/04)
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