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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 12/05/2023
Date Signed: 12/05/2023 09:43:29 AM


Document Has Been Signed on 12/05/2023 09:43 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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, THEFACILITY NUMBER:
079200962
ADMINISTRATOR:HARRISON, NANCYFACILITY TYPE:
740
ADDRESS:12720 ALCOSTA BLVDTELEPHONE:
(925) 725-1485
CITY:SAN RAMONSTATE: CAZIP CODE:
94583
CAPACITY:95CENSUS: 68DATE:
12/05/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Kiel Stromgren, Memory Care DirectorTIME COMPLETED:
09:55 AM
NARRATIVE
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On 12/5/2023 starting at 8:45 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a Case Management visit as a result of complaint. (CN# 15-AS-20220817112257). AGPA met with Memory Care Director, Laquisha Wong and explained the purpose of the visit. AGPA later met with Executive Director, Kiel Stromgren.

During a visit on September 20, 2022, the Department attempted to review three residents records. However, the records maintained for 3 of 3 staff (S1, S2 and S3) were incomplete. 3 of 3 staff did not have application and contact information on file. In addition, there were no record of termination date and reason for termination for S2. The Department discussed the issue with former Resident Care Director, Sangeeta Devi and an email was sent regarding staff files.

The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency 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 HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette FranciscoTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
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 12/05/2023 09:43 AM - 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
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: 12/05/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/01/2023
Section Cited
CCR
87412(a)

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87412(a) PERSONNEL RECORDS
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:
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By POC date, Administrator will review regulation and submit self-certification letter to CCLD.
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This requirement is not met as evidenced by: Based on record review, Licenssee did not comply with the regulation cited above by not having S1, S2 and S3's application and contact information on file. In addtiion, no record of reason for termination and termination date for S2 were on file which poses a potential health, safety and 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: 12/05/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/05/2023
LIC809 (FAS) - (06/04)
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