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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:56:50 PM


Document Has Been Signed on 09/11/2024 04:56 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: 76DATE:
09/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Executive Director, Kiel StromgrenTIME COMPLETED:
05:15 PM
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On 09/11/2024 at 9:30 AM Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a 1-Year Annual Required visit. LPA met with Executive Director (ED), Kiel Stromgren and Resident Care Director, Ashley Paris and explained the purpose of the visit.

LPA toured facility with ED including but not limited to random resident's bedrooms, bathrooms, kitchen, common areas, and outdoor area. There are no bodies of water observed. Indoor and outdoor passageways are kept free of obstruction. Room temperature in the hallway is maintained at 72 degrees F. Hot water temperature in random residents’ bathroom is maintained at 111.5, 116.1 and 110.8 degrees F. Random resident's bathrooms were equipped with grab bars and non-skid mats. Hygiene supplies were available for residents. There is a minimum of one week supply of non-perishable and 2-day perishable foods. Refrigerator temperature was maintained at 34 degrees F and freezer temperature was maintained below 0 degrees F.

Smoke detectors are interconnected with sprinklers and observed throughout the facility. Fire extinguisher was last serviced on 8/23/2024. Fire and Earthquake Drill was last conducted on 8/24/2024. Emergency Disaster Plan was last posted on 5/01/2024. Orkin last came out for maintenance 6/19/2024. LPA observed facility van to be clean and up to date on registration.

LPA reviewed 5 staff records. 5 of 5 staff are associated. LPA reviewed 5 resident records and 5 of 5 have current first aid training and are associated to the facility. LPA reviewed a sample of resident's medications.

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: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024
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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