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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 011440777
Report Date: 12/12/2023
Date Signed: 12/12/2023 03:03:41 PM


Document Has Been Signed on 12/12/2023 03:03 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:WATERS EDGE LODGEFACILITY NUMBER:
011440777
ADMINISTRATOR:LAGASCA-CRUZ, MARIE ANN NFACILITY TYPE:
740
ADDRESS:801 ISLAND DRIVETELEPHONE:
(510) 748-4300
CITY:ALAMEDASTATE: CAZIP CODE:
94502
CAPACITY:120CENSUS: 63DATE:
12/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Marie Ann Lagasca-Cruz, AdministratorTIME COMPLETED:
03:15 PM
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On 12/12/23 at 10:30 a.m.,Licensing Program Analyst (LPA) Greg Clark arrived unannounced to conduct 1-Year Annual Required inspection. LPA met with Administrator, Marie Ann Lagasca-Cruz and explained the purpose of the visit. The facility’s fire clearance was approved for 120 residents.

LPA toured facility including but not limited to 5 resident apartments, bathrooms, kitchen, common area and backyard. All outdoor and indoor passageways are kept free of obstruction. There are no bodies of water observed. A comfortable temperature is maintained at 70 degrees Fahrenheit. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. The hot water temperature in the residents’ bathrooms was measured at 107.5, 107.8 and 112.5 degrees Fahrenheit. Residents’ bathrooms are equipped with grab bars and non-skid mats. There is a minimum of one week supply of non-perishable and 2 day of perishable foods. Centrally stored medication and sharps were locked and inaccessible to residents.

Smoke detectors and carbon monoxide detectors were in operating condition during visit. Fire extinguisher was last serviced on 8/10/23. First aid kit was observed to be complete.

LPA reviewed 5 residents records and 5 staff records; all were complete. LPA also reviewed a sample of resident’s medications.

Updated copies of the following document was requested for facility file and are to be submitted to CCL by 12/19/23: LIC 610E Emergency Disaster Plan


No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.
SUPERVISOR'S NAME: Yvonne Flores-LariosTELEPHONE: (510) 286-0517
LICENSING EVALUATOR NAME: Gregory ClarkTELEPHONE: 510-285-3927
LICENSING EVALUATOR SIGNATURE:
DATE: 12/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/12/2023
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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