079200962-12-30-2024-15-AS-AGOZ-DCG43E-20241230174434

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 12/30/2024
Date Signed: 12/30/2024 05:44:46 PM

Document Has Been Signed on 12/30/2024 05:44 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, THE		FACILITY NUMBER:	079200962
ADMINISTRATOR/ DIRECTOR:	HARRISON, NANCY		FACILITY TYPE:	740
ADDRESS:	12720 ALCOSTA BLVD		TELEPHONE:	(925) 725-1485
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY: 95	TOTAL ENROLLED CHILDREN: 0	CENSUS: 76	DATE:	12/30/2024
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	03:00 PM
MET WITH:	Executive Director, Kiel Stromgren		TIME VISIT/ INSPECTION COMPLETED:	06:15 PM

NARRATIVE

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On 12/30/2024 at 3:00PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management review related to complaint 15-AS-20240514173549. Upon arrival, LPA met with Kiel Stromgren, Executive Director, and explained the purpose of the visit. The facility is licensed for 95 non-ambulatory of which 15 may be bedridden.

During the course of the investigation, The Department conducted interviews, and reviewed files. It was discovered that staff were not adequately trained to meet the facility’s operational needs, as required by state licensing standards. Several staff members were found to be unfamiliar with key procedures and protocols that are critical for maintaining quality care and ensuring the safety of residents. In addition to the lack of training, the department found that the facility was not properly maintaining resident or staff records, which is a violation of regulatory requirements. Upon review, it was determined that several records that should have been readily available, including incident reports and other key documentation, were missing or incomplete. The facility was unable to provide the requested incident reports to the Department and the Department did not have record of the incident reports being submitted by the facility.

Report Continues on LIC809-C

Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
Alona Gomez	TELEPHONE: 510-239-1306
	DATE: 12/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

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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Document Has Been Signed on 12/30/2024 05:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Facility personnel shall at all times be sufficient ... facility require such additional staff for the provision of adequate services. This requirment is not met as evidence by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	By POC The Facility agrees to review staffing and conduct random assesments of employees and provide training as neccessary and provide the assesments to CCLD

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
Alona Gomez	TELEPHONE: 510-239-1306
	DATE: 12/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/30/2024 05:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 12/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Section Cited

Each licensee shall furnish... (1)A written report shall be submitted ...and disposition of the case. This requirment is not met as evidence by:
	Deficient Practice Statement
1 2 3 4
	POC Due Date: 01/15/2025
	Plan of Correction
1 2 3 4	By POC The Facility agrees to review regulations and provide a memo to all staff and provide CCLD with a copy of memo.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
Alona Gomez	TELEPHONE: 510-239-1306
	DATE: 12/30/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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
	VISIT DATE: 12/30/2024

NARRATIVE

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THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING INVESTIGATION:

· Staff are not adequately trained to provide care
· Facility is not maintaining required documents
· Facility is not following proper reporting procedures

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 12/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024

LIC809 (FAS) - (06/04)

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