019200708-7-13-2023-15-AS-GLUK-CTQ2DT-20230713171853

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 019200708
Report Date: 07/13/2023
Date Signed: 07/13/2023 05:19:00 PM

Document Has Been Signed on 07/13/2023 05:19 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:	WATERMARK AT ROSEWOOD GARDENS, THE		FACILITY NUMBER:	019200708
ADMINISTRATOR:	HARRISON, NANCY		FACILITY TYPE:	740
ADDRESS:	35 FENTON STREET		TELEPHONE:	(925) 443-7200
CITY:	LIVERMORE	STATE: CA	ZIP CODE:	94550
CAPACITY:	115	CENSUS: 73	DATE:	07/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ranjeeta Kumar, Assisted Living Program Director		TIME COMPLETED:	05:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	On 7/13/2023 at 10:00AM, Licensing Program Analyst (LPA) G. Luk arrived unannounced to conduct a Required - 1 Year inspection. LPA met with Assisted Living Program Director, Ranjeeta Kumar. The facility’s fire clearance was approved for 115 non-ambulatory residents and 10 residents may be bedridden. LPA toured the facility including but not limited to bedrooms, bathrooms, dining area, activity rooms, kitchen, common areas, and outdoor area. Centrally stored medications were locked in medication carts located in med rooms. First Aid kit is complete. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Carbon monoxide detectors were observed. Fire extinguishers were observed to be full and last serviced on 2/14/2023. One week of nonperishable and 2-day of perishable food supplies were available. Facility orders food twice a week. Freezer’s temperature was registered at -10 degree F while the refrigerator’s temperature was recorded at 30 degrees F. Comfortable temperature was maintained inside the facility. Hot water temperature was measured at 120 degrees F in a resident's bathroom. Grab bars for each toilet and shower were installed. Non-skid mats were observed. There were adequate lights in each room. Resident rooms were observed to be cleaned and fully furnished. Indoor and outdoor passages were free of obstruction. (Continue on 809C...)

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

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 07/13/2023 05:19 PM - 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
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK AT ROSEWOOD GARDENS, THE	FACILITY NUMBER: 019200708
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87458(b)(1)

Medical Assessment

(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above by not having chest x-ray results for R2 and R3 which poses a potential health and safety risk to persons in care.
	POC Due Date: 08/04/2023
	Plan of Correction
1 2 3 4	Facility has agreed to obtain chest x-ray for R2 and R3. Facility will submit copies to CCLD by POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

Page: 2 of 5

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 ROSEWOOD GARDENS, THE	FACILITY NUMBER: 019200708
	VISIT DATE: 07/13/2023

NARRATIVE

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LPA reviewed 5 resident records starting at 12:00 PM.

At 2:00PM, LPA observed R2 and R3 does not have chest x-ray results on file during record review.

The deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiency may result in civil penalties.

LPA will return at a later time to complete the inspection.

Exit interview conducted. A copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace Luk	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 07/13/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/13/2023

LIC809 (FAS) - (06/04)

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