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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 03/05/2024
Date Signed: 03/05/2024 12:38:38 PM


Document Has Been Signed on 03/05/2024 12:38 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
OAKLAND ASC, 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 RAMONSTATE: CAZIP CODE:
94583
CAPACITY:95CENSUS: DATE:
03/05/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Kiel StromgrenTIME COMPLETED:
12:50 PM
NARRATIVE
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On 03/05/2024 at approximately 9:30AM, Licensing Program Analyst (LPA) A Gomez arrived unannounced to conduct a case management visit regarding an SOC 341 received 2/22/2024. Upon arrival LPA met with Executive Director (ED), Kiel Stromgren and explained the purpose of the visit.

On 2/22/2024 CCLD received an SOC 341 that stated that staff (S1) was found to be financially abusing resident (R1). On 2/21/24, it came to the attention of the Resident Care Director that R1 was observed potentially purchasing airline tickets while in the dining room for breakfast. Staff (S2) advised R1 to hang up the phone when they overheard the person on the phone and seeing R1's credit cards on the table, thinking it was a scam. The staff (S2) asked R1 what was happening and R1 stated they were purchasing flights to New York for them and and S1. S1 at time of incident was employed with Watermark as a Caregiver. The staff (S2) observed handwritten notes with flight numbers, times and the toll number to United Airlines. Staff (S2) immediately advised the Resident Care Director of the situation. The son of R1 was notified of the incident and possible credit card transaction and the son confirmed a $1400+ purchase was made for 2 flights to New York. Staff (S3) also advised the Resident Care Director that R1 had a package delivered to the community and when the staff (S3) assisted R1 with opening the package per their request it was a sweater and scarf. Staff (S2) reported the items were then seen being worn by S1. Executive Director, Human Resources and Resident Care Director all spoke with R1 and R1 confirmed they purchased the flights for them and S1 for a trip to New York. R1 also confirmed they bought S1 the sweater and scarf for Valentines Day.

During investigation LPA reviewed S1's file and obtained copies of disciplinary actions regarding this event, a copy of S1's ID, and contact information for S1. LPA also spoke with ED. The ED informed LPA that at the time of Disciplinary action S1 was wearing scarf purchased by R1. ED informed LPA that S1 did confirm that the sweater and scarf were a gift from R1. ED also informed LPA that when they went to talk to R1 that R1 stated that S1 had told them they had approved time off for trip to New York.

Report continues on LIC 809-C
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
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 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/05/2024
NARRATIVE
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During investigation LPA interviewed R1. R1 atated that they had their daughter purchase a sweater and scarf for S1 for valentines day and that they had asked S1 to come to New York to care for them. R1 informed LPA that it was understood that R1 would be fully financing the trip as well as paying S1 for their care giving services.

During investigation LPA interviewed S2. S2 informed LPA that she did witness R1 making a purchase for plane tickets and Them writing down information. When S2 asked R1 who the tickets were for R1 said for them and S1. S2 informed LPA that they immediately let their supervisor know.

During investigation LPA interviewed S3. S3 informed LPA that when R1 received a package that they assisted R1 in opening the package per R1's request. When S3 opened the package a scarf and pink sweater fell out. S3 asked R1 who the items were for ad R1 said themself. The following day S1 was seen by S3 and other staff wearing the sweater and scarf. S1 was also heard by multiple staff saying that they were a gift from R1.



The Following Deficiencies were Cited:
-Based on interviews S1 was found to have Financially abused R1.





The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

DATE: 03/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3
Document Has Been Signed on 03/05/2024 12:38 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
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: 03/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
03/31/2024
Section Cited
HSC
1569.269(a)(10)

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To be free from neglect, financial exploitation, involuntary seclusion, punishment, humiliation, intimidation, and verbal, mental, physical, or sexual abuse. This requirement was not met as evidenced by:
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By POC date the Executive Director agrees to retrain all staff on the cited regulation and self submit to CCLD.
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Based on the investigation, the licensee failed to comply with the section code cited above by S1 having finacialy abused R1
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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: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:
DATE: 03/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2024
LIC809 (FAS) - (06/04)
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