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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200962
Report Date: 12/30/2024
Date Signed: 04/10/2025 01:24:26 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
OAKLAND ASC, 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
05/14/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240514173549
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: 76DATE:
12/30/2024
UNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Executive Director, Kiel StromgrenTIME COMPLETED:
06:00 PM
ALLEGATION(S):
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Resident suffered a fall resulting in hospitalization.
Staff did not safeguard resident's personal item.
Staff did not follow physician's instructions.
INVESTIGATION FINDINGS:
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This is an amendment to an original LIC9099 report issued on 12/30/2024
On 4/10/2025 at 12:50 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver amended findings for the above allegation. LPA met with Executive Director, Kiel Stromgren and explained the purpose of the visit.

During the course of the investigation, the Department and LPA A. Gomez conducted interviews with staff, residents, and witnesses. Documents reviewed included R1’s admission agreement, care plan, physician’s report, emergency information, facility incident reports, staff schedules, medical records, and personal belongings inventory records.

Report Continues on LIC9099-C
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 5
Control Number 15-AS-20240514173549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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This is an amendment to an original LIC9099-C report issued on 12/30/2024

On the allegation that the resident suffered a fall resulting in hospitalization, the Department found during interviews, record reviews, and observations that R1 experienced multiple documented falls, including significant incidents on 1/26/2023 and 2/29/2024. These falls led to hospitalizations, with the fall on 2/29/2024 resulting in an intracerebral hemorrhage. R1’s care plan, updated after the 1/26/2023 fall, required the use of a walker and physical therapy to prevent further falls. However, staff interviews revealed that even after the physician’s report was updated requiring the use of walker, R1 frequently ambulated without his walker and often wore inappropriate footwear, such as flip-flops, which increased his fall risk. Staff members, including S1 and S2 confirmed that although they encouraged R1 to use the walker, they did not enforce this consistently nor did they implement any fall preventatives to ensure R1’s safety. R1 had a habit of walking to the kitchen during midnight Environmental observations also revealed that high-risk areas, such as the kitchen, were accessible to R1 without adequate supervision or physical barriers to restrict movement. Additionally, staff training records indicated that while fall prevention training was available, it was not effectively applied in practice, leading to lapses in supervision. Therefore, the allegation that the resident suffered a fall resulting in hospitalization is substantiated.

On the allegation that staff did not safeguard the resident’s personal items, the Department found during interviews, record review, and observations that there were inconsistencies in the documentation and securing of R1’s belongings. The investigation included a review of R1’s personal belongings inventory, which revealed gaps in the documentation of items. Interviews with staff, including S1 and S4, indicated that staff shortages and high turnover contributed to lapses in securing residents’ personal items. S4 admitted that personal items were sometimes left unsecured, particularly during busy shifts, which increased the potential for loss or misplacement. R1’s family also reported missing items and noted that these belongings had not been accounted for during their last visit.

Report Continues on LIC9099-C
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20240514173549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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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This is an amendment to an original LIC9099-C report issued on 12/30/2024

Continued from LIC9099-C

The facility lacked protocols for safeguarding resident belongings, and staff confirmed that procedures to secure items were not consistently followed. Therefore, the allegation that staff did not safeguard the resident’s personal items is substantiated.

On the allegation that staff did not follow physician’s instructions, the Department found during interviews, record review, and observations that R1’s care plan, updated following his fall on 1/26/2023, mandated the use of a walker and continuous supervision due to their high fall risk. Interviews with multiple staff members, including S2 and S3, indicated that although staff were aware of the requirement, R1 frequently moved around the facility without their walker and unassisted. Facility incident reports documented instances where R1 was observed walking without the walker and without staff supervision, as required by R1’s care plan. Despite these incidents, no documented corrective actions were taken to ensure compliance with the physician’s instructions. Additionally, statements from R1’s family expressed concerns over the lack of adherence to the care plan, noting that R1 was often seen ambulating unassisted. The evidence shows that the facility did not consistently follow the physician’s instructions to mitigate R1’s risk of falling. Therefore, the allegation that staff did not follow physician’s instructions is substantiated.


****An immediate civil penalty of $500 is being assessed on todays date****


The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Substantiated findings will be reviewed for possible enhanced civil penalty assessment.

Exit interview conducted with Executive Director. A copy of this report and appeal rights was provided.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 15-AS-20240514173549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/15/2025
Section Cited
CCR
87217(b)
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(b) Every facility shall take appropriate measures to safeguard ...resources.
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By POC date Facility agrees to review regulations and notify CCLD.
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Based on interviews and record review the staff did not adhere to the requirement above by having gaps in records of residents personal items or safety measures in place which posed a potential personal rights risk to clients 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.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20240514173549
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/15/2025
Section Cited
HSC
1569.269(a)(10)
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(a)Residents...shall have all of the following rights: (10) To be free from neglect,...or sexual abuse
This requirement is not met as evidence by:
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By POC Facility agrees to review regulations and provide staff with a memo on expectations and following physicians orders and provide CCLD a copy of the memo. $500 civil penalty assessed
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Based on record review and interviews the facility did not follow physician's instructions which resulted in R1 falling multiple times leading to hospitilization which posed an immediate safety risk to person in care.
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Type A
01/15/2025
Section Cited
CCR
87468.2(a)(4)
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(a)In addition to the rights listed in Section 87468.1...elderly shall have...rights: (4)To care, supervision...that meet their individual needs and are delivered ... to meet their needs.
This requirement is not met as evidence by:
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By POC Facility agrees to review regulations and provide staff on a training on observations and assisting residents. Facility also agrees to review regulations relating to when to update residents care plans and notify CCLD.
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Based on record review and interviews the facility did not adress R1's fall risk after observing them not utilizing their walker resulting in R1 falling multiple times and being hospitilized with an intracerebral hemorrhage which posed an immediate health and safety risk to person 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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5