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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 09/29/2022
Date Signed: 09/29/2022 05:49:07 PM


Document Has Been Signed on 09/29/2022 05:49 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
CCLD Regional Office, 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: 38DATE:
09/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Sangeeta Devi, Resident Care DirectorTIME COMPLETED:
06:05 PM
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On 9/29/2022 starting at 2:20 PM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander conducted a Health & Safety inspection as a result of a priority 2 complaint. LPAs met with Resident Care Director, Sangeeta Devi.

LPAs toured facility with Resident Care Director including but not limited to the apartments, bathrooms, common areas, kitchen, and outdoor area. Hot water temperature was measured at 110.6 degrees F in the a random resident bathroom. 7-day of non-perishable and 2-day of perishable food supplies were sufficient. Refrigerator temperature was observed at 40 degrees F. Resident's medications were kept locked in the med room. Smoke detectors are interconnected with the sprinkler system. Carbon monoxide detector was observed. Fire extinguisher was observed to be full and last serviced on 9/1/2022. There are no accessible bodies of water observed. Indoor and outdoor passageways are free of obstruction. Facility appear to be safe and there are no imminent health/safety concerns on today's date.

Exit interview conducted with Resident Care Director and a copy of report provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 09/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/29/2022
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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