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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 05/30/2024
Date Signed: 05/30/2024 04:30:23 PM


Document Has Been Signed on 05/30/2024 04:30 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: 74DATE:
05/30/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Memory Care Director, Laquisha WongTIME COMPLETED:
04:40 PM
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On 5/30/2024 at 3:00 PM, Licensing Program Analyst (LPA) A. Gomez conducted a Health & Safety inspection as a result of a priority 2 complaint. LPA met with Memory Care Director, Laquisha Wong and explained the purpose of the visit.

LPA toured facility including but not limited to the random bedrooms, bathrooms, common area, kitchen, and outdoor area. Hallway temperature was observed at 72 degrees F. Hot water temperature was measured at 112.5, 112.1, and 112.5 degrees F in rooms # 204, 227, and 205 bathrooms. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Facility orders food supplies on a weekly basis. Refrigerator temperature was observed at 39 degrees F. Freezer temperature was observed at 0 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. First-aid kit was complete. Fire extinguisher was observed to be full and last serviced on 5/1/2024. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction.

No deficiencies cited during visit. Exit interview conducted 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: 05/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/30/2024
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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