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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200962
Report Date: 08/08/2024
Date Signed: 08/08/2024 04:41:17 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240327085953
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:
08/08/2024
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Executive Director, Kiel StromgrenTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff did not provide medical attention to resident.
INVESTIGATION FINDINGS:
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On 8/8/2024 at 11:50 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a complaint visit and deliver findings. LPA explained the purpose of the visit to Executive Director, Kiel Stromgren.

During the course of the investigation through document review and interview LPA was unable to determine if R1 received the proper medical attention. LPA interviewed 6 staff members. LPA was unable to obtain a injury assesment form for R1. R1 was unable to be interviewed due to dementia and a language barrier. S6 states that they did a quick assessment of R1 and spent more time assessing R2. According to interviews R1 did not receive a thorough assesment. The facility only noticed the injuries once the responsible party pointed them out.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/27/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240327085953

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:
08/08/2024
UNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Executive Director, Kiel StromgrenTIME COMPLETED:
05:00 PM
ALLEGATION(S):
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Staff mismanaged resident’s medication.
Staff does not prevent resident from going into other residents rooms.
Staff did not provide adequate supervision.
INVESTIGATION FINDINGS:
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On 8/8/2024 at 11:50 AM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a complaint visit and deliver findings. LPA explained the purpose of the visit to Executive Director, Kiel Stromgren.

During the course of the investigation LPA interviewed 6 staff., Reviewed Staff roster, resident roster for memory care, Staff schedules for March 2024, MAR for Memory Care, Unusual Incident reports for R1 and R2. Based on the review LPA did not see a medication mismanagment. Based on review R1 or R2 did not require additional suppervision. Based on interviews staff followed procedures on preventing residents from entering others rooms.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona GomezTELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:

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

DATE: 08/08/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 15-AS-20240327085953
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/08/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/15/2024
Section Cited
CCR
87465(j)
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(j) In all facilities licensed for sixteen (16) persons... responsibility for assuring that each resident receives needed first aid ... known to all residents and staff.

This regulation is not met as evidence by:
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By POC date ED agrees to provide trainings on reporting requirements, documention, and how to asses for injuries and notify CCLD
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Based on record review and Interview the licensee did not comply with the section cited above by not completing a thourough assesment of resident which resulted in missed minor injuries which posed a potential safety risk to residents in care.
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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: 08/08/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3