019200874-10-27-2022-15-AS-KHOS-CL2M2L-20221110081344

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 10/27/2022
Date Signed: 10/27/2022 01:04:43 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/20/2022 and conducted by Evaluator Catherine Lin

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20221020103814

FACILITY NAME:	WATERMARK BY THE BAY, THE		FACILITY NUMBER:	019200874
ADMINISTRATOR:	HALL, STEPHANIE J		FACILITY TYPE:	740
ADDRESS:	1440 40TH STREET		TELEPHONE:	(510) 594-8800
CITY:	EMERYVILLE	STATE: CA	ZIP CODE:	94608
CAPACITY:	175	CENSUS: 63	DATE:	10/27/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Stephanie Hall, Executive Director		TIME COMPLETED:	01:15 PM

ALLEGATION(S):

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Staff do not afford resident respect in their relationship
Staff will not allow resident to go outside
Staff do not take resident on outing
Staff did not safeguard residents clothing

INVESTIGATION FINDINGS:

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On 10/27/22 at 10:30am, Licensing Program Analyst (LPA) Catherine Lin conducted an unannounced subsequent complaint investigation regarding the above allegations and deliver investigation findings. LPA explained the purpose of the visit with the Executive Director, Stephanie Hall.

Allegation: Staff do not afford resident respect in their relationship – unsubstantiated
The Department has investigated this allegation and per interviews and record review and found that no sign of disrespectful to residents was observed during visits. Witnesses (W1, W2, and W3) have not seen that any staff disrespect to any resident during their visiting. Resident R1 stated that staff and residents have good relationship in facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20221020103814

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK BY THE BAY, THE	FACILITY NUMBER: 019200874
	VISIT DATE: 10/27/2022

NARRATIVE

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Allegation: Staff will not allow resident to go outside – unsubstantiated
The Department has investigated this allegation and per interviews and record review and found that residents in memory care unit will not allow to go outside of facility without assisted which is in compliance.

Allegation: Staff do not take resident on outing – unsubstantiated
The Department has investigated this allegation and per interviews and record review and found that facility has posted activities schedules each month. Residents R1 and R2 stated that they went out to a pumpkin patch last week and were able to show pictures. Residents R3, R4, and R5 stated that there was a walking club to parks that they joined once a while.

Allegation: Staff did not safeguard residents clothing – unsubstantiated
The Department has investigated this allegation and per interviews and document review and found that resident’s (R1) clothing was missed before moving into facility, R2, R3, and R4 disagreed that facility staff didn’t safeguard clothing while living in facility.

Although the allegations may have happened or is valid, there is not a preponderance of evidence to provide the alleged violations did occur, therefore the allegations are unsubstantiated.

No deficiencies cited. Exit interview conducted with Executive Director and a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Catherine Lin	TELEPHONE: 510-622-2053
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC9099 (FAS) - (06/04)

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