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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200962
Report Date: 04/24/2025
Date Signed: 04/24/2025 03:03:01 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
07/29/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240729122132
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: 75DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Kiel StromgrenTIME COMPLETED:
01:51 PM
ALLEGATION(S):
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Staff are not showering the residents
Staff are not ensuring the residents are properly dressed and groomed
Staff allow the residents to sleep on wet and dirty sheets
Staff did not properly report an incident involving a resident
Staff are not meeting the residents diabetic needs
INVESTIGATION FINDINGS:
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On 04/24/2025 at 1:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver complaint findings for the above allegations. LPA met with Executive Director Kiel Stromgren and explained the purpose of the visit.

During the course of the investigation, LPA interviewed staff and residents, toured the facility, and reviewed documentation including but not limited to disciplinary records, care notes, in-service training logs dated 12/12/24, 12/17/24, and 03/26/25, text message correspondences between management and staff, and documentation submitted by the W1.

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

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
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 8
Control Number 15-AS-20240729122132
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: 04/24/2025
NARRATIVE
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On the allegations that staff were not showering residents, Staff are not ensuring the residents are properly dressed and groomed, Staff allow the residents to sleep on wet and dirty sheets, Staff did not properly report an incident involving a resident , and Staff are not meeting the residents diabetic needs the following was found:

Interviews and document reviews confirmed that residents were not consistently receiving showers. End-of-shift reports documented that showers had been completed, but this conflicted with observations recorded in disciplinary documentation. Memory Care Director stated that they had received complaints from staff regarding inconsistent hygiene practices and personally observed residents who had not been bathed. Memory Care Director also reported that S2 “would lie and say she tried to shower residents but wouldn’t follow through.” Disciplinary documentation issued to S2 on 01/23/25 confirmed that Resident was observed with a soiled bed, a soiled brief on the floor, and a soiled comforter nearby. S2 received a final written warning as a result. Similarly, S3 received a final written warning dated 01/24/25 after Resident was found following an unwitnessed fall with blood in the shower, urine on the sheets and bed protector, and a dirty brief under the sink. The room had not been cleaned. These incidents were formally documented and observed by facility management.

Residents were also not consistently groomed or dressed. Memory Care Director reported having observed multiple residents still in pajamas late into the day and confirmed that some staff were not assisting residents with dressing. It was also reported that there were residents that were have found put in bed with their daytime clothing and not dressed out for bed at night. Documentation further supported that residents were allowed to sleep on wet and dirty bedding. The disciplinary notice for S2 referenced a resident found in a soiled bed with visibly unclean linens. The notice for S3 detailed the condition of a resident room where urine and blood were present, and incontinence items had not been disposed of. These were documented observations that resulted in disciplinary action. Memory Care Director also confirmed knowledge of incidents where residents bedding was left soiled by staff.

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

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 8
Control Number 15-AS-20240729122132
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: 04/24/2025
NARRATIVE
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Report Continued from LIC9099-C

Although the facility conducted in-service training on reporting expectations on 12/12/24 and 03/26/25, record reviews and interviews showed that staff were not consistently reporting incidents as required. Memory Care Director stated, “Staff have scratched off concerns on end-of-shift reports instead of reporting incidents.” Corrective action followed these reporting failures. Because staff where failing to follow the proper reporting requirements CCL did not receive reports as required. The investigation also confirmed that staff did not consistently meet the diabetic needs of residents. Memory Care Director reported that staff were observed giving sugary beverages to residents with diabetic diagnoses and had to be directed to stop. Care plans for diabetic residents contained specific dietary instructions that were not being followed. No documentation was available showing oversight or review of adherence to these care plans. Review of text messages also confirmed concerns from staff that other staff members were not effictively providing care to residents as required.

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.
SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 8
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
07/29/2024 and conducted by Evaluator Alona Gomez
COMPLAINT CONTROL NUMBER: 15-AS-20240729122132

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: 75DATE:
04/24/2025
UNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director Kiel StromgrenTIME COMPLETED:
01:51 PM
ALLEGATION(S):
1
2
3
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5
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8
9
Staff are not feeding the residents
Staff are not ensuring the residents are consuming an appropriate amount of fluids
Staff are allowing the residents to eat food with ants
Staff do not prevent a resident from attacking other residents
INVESTIGATION FINDINGS:
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On 04/24/2025 at 1:30 PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to deliver complaint findings for the above allegations. LPA met with Executive Director Kiel Stromgren and explained the purpose of the visit.

During the course of the investigation, LPA interviewed staff and residents, toured the facility, and reviewed documentation including but not limited to disciplinary records, care notes, in-service training logs dated 12/12/24, 12/17/24, and 03/26/25, text message correspondences between management and staff, and documentation submitted by the W1.

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

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 8
Control Number 15-AS-20240729122132
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: 04/24/2025
NARRATIVE
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On the allegations that staff were not feeding residents, staff are not ensuring the residents are consuming an appropriate amount of fluids, Staff are allowing the residents to eat food with ants, and Staff do not prevent a resident from attacking other residents, the following was found:

There was no documentation to support that residents were denied meals. Staff and supervisory interviews confirmed that feeding support is provided only with physician orders. Interviews with residents produced that all residents were satisfied with their food service. The kitchen was also observed fully stocked. Memory Care Director confirmed that staff had previously fed residents on the first floor, but that practice ended unless feeding orders were in place. On the allegation that staff were not ensuring adequate hydration in-service training focused on hydration was conducted on 12/12/24. Memory Care Director stated that “after the in-service, hydration improved,” however prior to in service training there was not documented incidents were residents were not consuming enough fluids. The facility did experience an ant infestation in the summer of 2024, but extermination services were called, and the issue was addressed. LPA previously had obtained extermination records and observed the facility to be free of ants. There was no evidence presented that residents consumed food with ants. While ants were documented in some resident rooms, neither interviews nor facility records confirmed that food contamination occurred. The allegation that staff failed to prevent resident-to-resident aggression could not be substantiated. LPA reviewed incident logs, internal reports, and conducted interviews with staff and residents. No documentation or statements supported that any physical aggression between residents occurred during the investigation window. Staff where able to identify de-escalation techniques when asked.

Based on the information obtained, the above allegations are unsubstantiated.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

SUPERVISORS NAME: Yvonne Flores-Larios
LICENSING EVALUATOR NAME: Alona Gomez
LICENSING EVALUATOR SIGNATURE:

DATE: 04/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 8
Control Number 15-AS-20240729122132
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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2025
Section Cited
CCR
87211(a)
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(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:

This requirement was not met as evidence by:
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An in service was conducted to staff and regulation reviewed POC clear.
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Based on record review and Interview the licensee did not comply with the section cited above by staff not properly reporting incidents which posed a potential safety and personal rights risk to residents in care.
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Type B
04/24/2025
Section Cited
CCR
87555(b)(7)
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(b) The following...shall apply:(7) Modified diets prescribed...shall be provided.

This requirement was not met as evidence by:
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An in service was conducted to staff and regulation reviewed POC clear.
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Based on Interview the licensee did not comply with the section cited above by staff not following residents diabetic needs which posed a potential health and safety risk to residents 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: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 8
Control Number 15-AS-20240729122132
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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2025
Section Cited
CCR
87307(3)(C)
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(3) Equipment ... assure provision of:(C) Clean linen...ensure that clean linen is in use by residents...shall be prohibited.

This requirement was not met as evidence by:
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An in service was conducted to staff and regulation reviewed POC clear.
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Based on record review and Interview the licensee did not comply with the section cited above by allowing residents to sleep in wet linens which posed a potential personal rights risk to residents in care.
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Type B
04/24/2025
Section Cited
CCR
87411(a)
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(a) Facility personnel shall at all times be...competent to provide the services necessary to meet resident needs...for the provision of adequate services.

This requirement was not met as evidence by:
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An in service was conducted to staff and regulation reviewed. Additionally staff received write ups and additional training. POC clear.
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Based on record review and Interview the licensee did not comply with the section cited above by staff not providing showers to residents which posed a potential personal rights risk to residents 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: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 8 of 8
Control Number 15-AS-20240729122132
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: 04/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/24/2025
Section Cited
CCR
87464(f)(4)
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(f) Basic services shall at a minimum include(4)Personal assistance...with...dressing...as specified in Section 87608, Postural Supports.

This requirement was not met as evidence by:
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An in service was conducted to staff and regulation reviewed POC clear.
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Based on Interview the licensee did not comply with the section cited above by staff not assisiting residents with dressing which posed a potential personal rights risk to residents 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: 04/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 8