079200962-12-1-2023-15-AS-KHOS-CYFJNC-20231212061142

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200962
Report Date: 12/01/2023
Date Signed: 12/01/2023 02:01:52 PM

Unsubstantiated

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
09/27/2022 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20220927151144

FACILITY NAME:	WATERMARK AT SAN RAMON, THE		FACILITY NUMBER:	079200962
ADMINISTRATOR:	HARRISON, NANCY		FACILITY TYPE:	740
ADDRESS:	12720 ALCOSTA BLVD		TELEPHONE:	(925) 725-1485
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	95	CENSUS: 71	DATE:	12/01/2023
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kiel Stromgren, Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

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Staff inappropriately kissed a resident in care
Resident sustained multiple unexplained injuries
Insufficient staffing to meet resident needs

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 reviewed records, collected documents, interviewed staff and resident (R1). It was alleged staff inappropriately kissed resident in care. AGPA interviewed 7 staff. 4 of 7 staff stated they heard a staff kissed R1, 2 of 7 stated they never heard or witnessed of staff kissing R1, and 1 of 7 stated of witnessing staff kissed R1 on the lips. AGPA interviewed R1 and R1 denied S1 kissing R1 on the lips. Due to conflicting interviews, AGPA was unable to prove or disprove allegation.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (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)

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Control Number 15-AS-20220927151144

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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It was alleged resident sustained multiple unexplained injuries and has insufficient staffing to meet resident needs. Based on information obtained by complainant, residents are sustaining unexplained injuries due to short staffing. AGPA reviewed a sample of 4 residents records and 4 of 4 residents does not need 1 on 1 care. Although R2 sustained an injury from an unwitnessed fall on 1/9/22, R2 did not require 1 on 1.

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

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

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (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)

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