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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 342701364
Report Date: 05/07/2026
Date Signed: 05/22/2026 06:49:12 PM

Document Has Been Signed on 05/22/2026 06:49 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WATERVIEW RESIDENCEFACILITY NUMBER:
342701364
ADMINISTRATOR/
DIRECTOR:		VIZCARRA, RHAYMONDFACILITY TYPE:
740
ADDRESS:6855 WATERVIEW WAYTELEPHONE:
(650) 303-2522
CITY:SACRAMENTOSTATE: CAZIP CODE:
95831
CAPACITY: 6CENSUS: 5DATE:
05/07/2026
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:15 PM
MET WITH:Kevin Valino and Aly RamirezTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On May 07, 2026, at 1:15 PM, Licensing Program Analyst (LPA) Avelina Martinez made an unannounced visit to this facility to conduct an annual required inspection. LPA Martinez met with Kevin Valino and Aly Ramirez and explained the purpose of today's visit.

LPA Martinez conducted a continuation annual inspection to review Medication Administration Records (MAR) for three residents. Resident 1 (R1) Centrally Stored Medication and destruction record was not complete. Resident 3 (R3) Centrally Stored Medication and destruction record had three entries for Famotidine Tab 20 mg with the same RX number, and the three entries had different start dates, expiration dates, and filled dates. R3's had two medication bottles for Venlafaxine ER 1500MG Capsules. One bottle start date was February 23, 2026, with a quantity of 90 pills, and as of May 07, 2026, there are 47 pills left in bottle. The second bottle start date is April 30, 2026 with a quantity of 15 pills, and as of May 07, 2026, there are 14 pills left in the bottle.

Based on this annual inspection, the facility was cited incidental 87465 (a)(4) Incidental Medical and Dental Care and 87465 (a)(6) Incidental Medical and Dental Care.

An exit interview was conducted, and a copy of this 809 report, 809 D Page, and Appeals rights were provided to the facility.

NAME OF LICENSING PROGRAM MANAGER: Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM ANALYST: Avelina Martinez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/07/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/07/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 05/22/2026 06:49 PM - It Cannot Be Edited


Created By: Avelina Martinez On 05/07/2026 at 02:50 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WATERVIEW RESIDENCE
FACILITY NUMBER: 342701364

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/07/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465 (a)(4) Incidental Medical and Dental Care…A plan for incidental medical and dental care shall be developed by each facility…. The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not ensure that staff were assisting residents with medication administration which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Facility staff agrees to email LPA Martinez Incidental and Medical and Dental Care in-service training agenda by 05/08/2026 by 5:00 PM. The in-service training must be conducted by a contracted medical professional and completed by POC date 05/21/2026. Facility staff agrees to email LPA Martinez in-service training document by 05/21/2026 5:00 PM.
Type A
Section Cited
CCR
87465(a)(6)
87465 (a)(6) Incidental Medical and Dental Care…A plan for incidental medical and dental care shall be developed by each facility…. When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.


This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not ensure staff were maintaining a record of dosages of medication and ensuring residents were administered their medication, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 05/08/2026
Plan of Correction
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Facility staff agrees to email LPA Martinez Incidental and Medical and Dental Care in-service training agenda by 05/08/2026 by 5:00 PM. The in-service training must be conducted by a contracted medical professional and completed by POC date 05/21/2026. Facility staff agrees to email LPA Martinez in-service training document by 05/21/2026 5:00 PM.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Czarrina A Camilon-Lee
NAME OF LICENSING PROGRAM MANAGER:
Avelina Martinez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 05/07/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2026


LIC809 (FAS) - (06/04)
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