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Department of
SOCIAL SERVICES

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, THEFACILITY NUMBER:
079200962
ADMINISTRATOR/
DIRECTOR:		HARRISON, NANCYFACILITY TYPE:
740
ADDRESS:12720 ALCOSTA BLVDTELEPHONE:
(925) 725-1485
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY: 95CENSUS: 76DATE:
12/30/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Executive Director, Kiel StromgrenTIME 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
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
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
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


Created By: Alona Gomez On 12/30/2024 at 03:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2025
Section Cited
CCR
87411(a)

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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:
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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
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Based on observation and record review, the licensee did not comply with the section cited above by not having adequete staff available which posed a potential safety and personal rights risk to persons in care.
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Type B
01/15/2025
Section Cited
CCR87506(e)

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(e)Original records or photographic reproductions shall be retained for a minimum of three (3) years following termination of service to the resident
This requirment is not met as evidence by:
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By POC The Facility agrees to review regulations and provide a training to required staff and notify CCLD
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Based on observation and record review, the licensee did not comply with the section cited above by not having requested documents which poses a potential personal rights risk to persons 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-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
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


Created By: Alona Gomez On 12/30/2024 at 03:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2025
Section Cited
CCR
87211(a)(1)

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Each licensee shall furnish... (1)A written report shall be submitted ...and disposition of the case.
This requirment is not met as evidence by:
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By POC The Facility agrees to review regulations and provide a memo to all staff and provide CCLD with a copy of memo.
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Based on observation and record review, the licensee did not comply with the section cited above by not having requested documents which poses a potential personal rights risk to persons 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-Larios
LICENSING EVALUATOR NAME:Alona Gomez
LICENSING EVALUATOR SIGNATURE:
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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
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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