079200962-9-29-2022-15-AS-LFRO-CJR2W9-20220929174509

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 09/29/2022
Date Signed: 09/29/2022 05:45:35 PM

Document Has Been Signed on 09/29/2022 05:45 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, THE		FACILITY NUMBER:	079200962
ADMINISTRATOR:	HARRISON, NANCY		FACILITY TYPE:	740
ADDRESS:	12720 ALCOSTA BLVD		TELEPHONE:	(925) 725-1485
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	95	CENSUS: 38	DATE:	09/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Sangeeta Devi, Resident Care Director		TIME COMPLETED:	06:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 9/29/2022 starting at 10:35 AM, Licensing Program Analysts (LPAs) L. Francisco and L. Alexander arrived unannounced to conduct Infection Control Inspection while at the facility for another matter. LPAs met with Resident Care Director (RCD), Sangeeta Devi and explained the purpose of the visit. During the Infection Control Inspection, LPA toured facility with RCD including but not limited to front entrance, screening station, hand washing stations, bedrooms, common areas, kitchen and courtyard. Facility has a sufficient 2-day perishable and one week non-perishable food supply. Visitors policy is posted on the front entrance. There is one central entry point for universal screening for staff, residents and visitors. A sign-in policy, thermometer and hand sanitizer were observed at screening station. Hand washing posters were observed. Common touched surfaces are disinfected at least twice daily. Bathrooms are equipped with liquid soap, paper towel and trash bin with touchless lids. Facility staff were observed to be wearing proper PPE. Facility has a 30-day supply of PPEs maintained at central location and easily accessible for staff. At 4:40 PM, LPAs reviewed 7 staff records and 2 of 7 have health screening and TB test on file. Facility has a mitigation plan and maintains record of routine screening for residents and staff. THE FOLLOWING DEFICIENCIES WERE OBSERVED: -At 2:40 PM, LPAs observed unlocked rubbing alcohol and cleaning spray underneath R1's bathroom sink cabinet. Deficiency cleared during visit. LPAs observed staff locked cabinet. -At 2:41 PM, LPAs observed unlocked scissors in R1's plastic drawer inside the bathroom. Deficiency cleared during visit. LPAs observed staff remove scissors from the drawers. REPORT CONTINUES ON 809C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (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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Document Has Been Signed on 09/29/2022 05:45 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
CCLD Regional Office, 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: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having scissors unlocked accessible to R1 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPAs observed staff remove scissors from R1's room In addition, Administrator will review regulation and conduct in-service training with staff and submit training agenda with staff signatures by 10/14/22.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above by having unlocked cleaning supply and rubbing alochol accessible to R1 which poses an immediate health and safety risk to persons in care.
	POC Due Date: 09/30/2022
	Plan of Correction
1 2 3 4	Deficiency cleared during visit. LPAs observed staff locked cabinet. In addition, Administrator will review regulation and conduct in-service training with staff and submit training agenda with staff signatures by 10/14/22.

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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK AT SAN RAMON, THE	FACILITY NUMBER: 079200962
	VISIT DATE: 09/29/2022

NARRATIVE

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Updated copies of the following documents were requested for facility file and are to be submitted to CCL by 10/7/2022:

LIC 308 Designation of Administrative Responsibility
LIC 309 Administrative Organization
LIC 500 Personnel Report
LIC 610E Emergency Disaster Plan
Liability Insurance
Current Administrator’s Certificate

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. 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: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/29/2022 05:45 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
CCLD Regional Office, 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: 09/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(f)

87411 Personnel Requirements - General (f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not obtaining health screening and TB test results for 5 of 7 staff prior to employment which poses a potential health & safety risk to persons in care.
	POC Due Date: 10/12/2022
	Plan of Correction
1 2 3 4	By POC date, Administrator will obtain health screening (LIC 503) with TB test result and submit a copy to CCL by POC date.

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.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2022

LIC809 (FAS) - (06/04)

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