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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 06/03/2024
Date Signed: 06/03/2024 01:12:14 PM


Document Has Been Signed on 06/03/2024 01:12 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
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 RAMONSTATE: CAZIP CODE:
94583
CAPACITY:95CENSUS: 72DATE:
06/03/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
11:25 AM
MET WITH:Ashley Paris, Resident Care Director TIME COMPLETED:
01:30 PM
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On 6/03/2024 at 11:25am, Licensing Program Analyst (LPA), Carol Fowler arrived unannounced to conduct a health and safety check as a result of the department receiving a phone call from the facility. LPA met with Ashley Paris, Resident Care Director and explained the reason for the visit.

Upon arrival, LPA was greeted the receptionist. During the health and safety check LPA toured the facility with the Kiel Stromgren Executive Director including but not limited to common areas, apartments/bedrooms and kitchen. LPA observed on the 2nd floor residents were having lunch and a couple of the residents were walking around. On the 1st floor LPA observed residents walking in common area. Facility is noted to be clean and in good repair and residents in care appear to be safe. There are no imminent health/safety concerns on today's date.

No deficiencies were cited today.

Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 06/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2024
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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