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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 08/13/2024
Date Signed: 08/13/2024 02:40:29 PM


Document Has Been Signed on 08/13/2024 02:40 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: 75DATE:
08/13/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Resident Care Director, Ashley ParisTIME COMPLETED:
02:50 PM
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On 8/13/2024 at 2:36 PM Licensing Program analyst (LPA) A. Gomez arrived unannounced to conduct a case management visit relating to the complaint investigation done on 8/8/2024. LPA met with Resident Care Director, Ashley Paris and explained the purpose of the visit.

On 8/8/2024 LPA came to the facility to conduct an initial 10-day complaint investigation and met with Executive Director, Kiel Stromgren. At the time of the visit LPA conducted the investigation under the wrong complaint number (15-AS-20240327085953). The correct complaint number is 15-AS-20240729122132. LPA amended the incorrect report and provided the facility with a copy of the amended report. LPA also provided the facility a copy of the correct report and report number.

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: 08/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/13/2024
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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