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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200962
Report Date: 12/01/2023
Date Signed: 12/01/2023 02:03:22 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/30/2023 and conducted by Evaluator Lizette Francisco
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20230130142212
FACILITY NAME:WATERMARK AT SAN RAMON, THEFACILITY NUMBER:
079200962
ADMINISTRATOR:HARRISON, NANCYFACILITY TYPE:
740
ADDRESS:12720 ALCOSTA BLVDTELEPHONE:
(925) 725-1485
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:95CENSUS: 71DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kiel Stromgren, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not administer resident's medications
INVESTIGATION FINDINGS:
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On 12/1/23 starting at 10:30 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegation. AGPA met with Executive Director, Kiel Stromgren and explained the purpose of the visit.

During the course of the investigation, AGPA obtained information, reviewed records, interviewed staff and interviewed residents., and collected including but not limited to the following documents: Physican's Report, Staff Roster, Residents Roster, Shower Log, Housekeeping Log, Client/Resident Personal Property And Valuables, and Care Plan.

It was alleged staff did not administer resident's medications. Based on information obtained by complainant, gabapentin was not being administered to R1.

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
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 5
Control Number 15-AS-20230130142212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERMARK AT SAN RAMON, THE
FACILITY NUMBER: 079200962
VISIT DATE: 12/01/2023
NARRATIVE
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On 12/1/23, AGPA obtained a printed Electronic Medication Administration Record (MAR) for R1 from November of 2022 to January of 2023. AGPA observed the following dates were not initialed by staff: 11/16/22, 12/15/22 and 12/27/22. S6 stated that if the MAR is blank, there may have been an internet issue and so staff will hand initial it on a Medication Administration Record. However, facility was not able to produce to AGPA a copy of the Medication Administration Record.

Based on AGPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report is provided to Executive Director.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
01/30/2023 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20230130142212

FACILITY NAME:WATERMARK AT SAN RAMON, THEFACILITY NUMBER:
079200962
ADMINISTRATOR:HARRISON, NANCYFACILITY TYPE:
740
ADDRESS:12720 ALCOSTA BLVDTELEPHONE:
(925) 725-1485
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:95CENSUS: DATE:
12/01/2023
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Kiel Stromgren, Executive DirectorTIME COMPLETED:
02:15 PM
ALLEGATION(S):
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Staff did not safeguard resident's personal belongings
Staff did not meet residents ADL needs
Due to insufficient staffing, resident's room is not cleaned
Due to insufficient staffing, resident's linens are not changed timely
INVESTIGATION FINDINGS:
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On 12/1/23 starting at 10:30 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to deliver findings for the above allegation. AGPA met with Executive Director, Kiel Stromgren and explained the purpose of the visit.

During the course of the investigation, AGPA obtained information, reviewed records, interviewed staff and interviewed residents., and collected including but not limited to the following documents: Physican's Report, Staff Roster, Residents Roster, Shower Log, Housekeeping Log, Client/Resident Personal Property And Valuables, and Care Plan.

It was alleged staff did not safeguard resident's personal belongings. However, based on interview with 4 staff, and 3 of 4 staff stated there is a system staff follows when doing resident's laundry.

REPORT CONTINUES ON 9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20230130142212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERMARK AT SAN RAMON, THE
FACILITY NUMBER: 079200962
VISIT DATE: 12/01/2023
NARRATIVE
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There is a sticky note placed on the washer machine and dryer with resident's name. In addition, S1 writes the name of the resident on the white board of which resident's clothes are currently in the washer and dryer machine. AGPA reviewed R1's Personal Property and Valuables, and did not observe any personal items listed for facility to safeguard.

It was alleged staff did not meet residents ADL needs. However, based on interview with 5 staff, residents are checked every 2 to 3 hours. On 11/8/23, AGPA interviewed 2 residents and 2 of 2 residents stated staff checks on them regularly, and if they need assistance, then they will use the call button. On 12/1/23, AGPA attempted to interview R1 and R2 but unable to obtain additional information.

It was alleged due to insufficient staffing, resident's room is not cleaned. On 11/8/23, AGPA interviewed 2 residents and 2 of 2 residents stated they have no issues with housekeeping. AGPA interviewed 4 staff and 4 of 4 staff stated housekeeping is completed once a week or as needed. On 12/1/23, AGPA attempted to interview R1 and R2, but unable to obtain additional information.

It was alleged due to insufficient staffing, resident's linens are not changed timely. On 11/8/23, AGPA interviewed 4 staff and 4 staff stated linens are changed once a week, or as needed if it's soiled or dirty. Interview with 2 residents revealed that staff changes their linens.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED.

Exit interview conducted and a copy of this report provided to Executive Director.

SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20230130142212
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK AT SAN RAMON, THE
FACILITY NUMBER: 079200962
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/01/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/08/2023
Section Cited
CCR
87468.2(a)(4)
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87468.2(a)(4) 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.
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By POC date, Adminsitrator agrees to review regulation with staff and submit a self-certification letter to CCLD.
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This requirement is not met evidenced by: Based on record review, Licensee did not comply with the regulation cited above by not administerting gabapentin to R1 on 11/16/22, 12/15/22, and 12/27/22 which poses a health and 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 12/01/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023
LIC9099 (FAS) - (06/04)
Page: 5 of 5