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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200962
Report Date: 02/23/2023
Date Signed: 02/23/2023 03:33:58 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
02/16/2023 and conducted by Evaluator Lizette Francisco
COMPLAINT CONTROL NUMBER: 15-AS-20230216161224
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: 49DATE:
02/23/2023
UNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Kiel Stromgren, Executive DirectorTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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Facility staff took down licensing and Ombudsman posters for filing a complaint.
Facility staff blocked door entrances with chairs to prevent residents from leaving the building.
INVESTIGATION FINDINGS:
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On 2/23/2023 at 2:10 PM Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct an initial 10-day complaint investigation for the above allegations. LPA met with Executive Director, Kiel Stromgren and Resident Care Director, Sangeeta Devi and LPA explained the purpose of the visit.

During the course of the investigation, LPA toured facility, obtained information and interviewed staff. It was alleged facility took down licensing and ombudsman posters for filing a complaint. Based on photos obtained, LPA observed ombudsman poster was not posted in the lobby. During an interview with 2 staff, LPA discovered that facility purchased a frame for the ombudsman poster and staff removed it temporarily until the frame arrives. On 2/23/2023, LPA observed CCLD complaint poster posted by the reception desk. However, size of poster was not the correct size of 20" x 26".

REPORT CONTINUES ON 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
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
Control Number 15-AS-20230216161224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/23/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/23/2023
Section Cited
CCR
87307(d)(6)
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PERSONAL ACCOMMODATIONS AND SERVICES
(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.
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DEFICIENCY CLEARED DURING VISIT. LPA observed exit is free of obstruction during tour of facility on 2/23/2023

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This requirement is not met as evidenced by: Based on photos obtained, Licensee did not comply with the regulation cited above. LPA observed two chairs blocking the exit door in memory care which poses a potential health, safety, personal rights risk to persons in care
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Type B
02/27/2023
Section Cited
CCR
87468.2(a)(10)
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87468.2(a)(10) ADDITIONAL PERSONAL RIGHTS OF RESIDENTS....
(a) In addition to the rights listed in Section 87468.1... (10) ....The licensee shall post the telephone numbers and addresses for the local offices of the State Department of Social Services and ombudsman program...the Welfare and Institutions Code, conspicuously in the facility foyer, lobby, residents’ activity room, or other location easily accessible to residents and their representatives.
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DEFICIENCY CLEARED DURING VISIT. LPA observed ombudsman poster was posted during tour of facility on 2/23/2023
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This requirement is not met as evidenced by: Based on photos obtained and interview, Licensee did not comply with the regulation cited above by not posting Ombudsman poster visible to residents and their representative which poses a potential personal rights 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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 15-AS-20230216161224
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 02/23/2023
NARRATIVE
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It was alleged facility staff blocked door entrance with chairs to prevent residents from leaving the building. Based on photos obtained, LPA observed 2 chairs obstructing the exit door in the Memory Care unit.

Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D.

Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 02/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2023
LIC9099 (FAS) - (06/04)
Page: 3 of 3