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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202775
Report Date: 08/22/2023
Date Signed: 08/22/2023 03:35:06 PM


Document Has Been Signed on 08/22/2023 03:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131



FACILITY NAME:WATERMARK AT ALMADEN, THEFACILITY NUMBER:
435202775
ADMINISTRATOR:ESTRELLADO, JULIE MAYFACILITY TYPE:
740
ADDRESS:4610 ALMADEN EXPRESSWAYTELEPHONE:
(669) 258-4567
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:240CENSUS: 110DATE:
08/22/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Executive Director, Ron EllenichTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced case management visit today and met with Executive Director (ED) Ron Ellenich.

The purpose of the case management visit was to follow up on an incident occurred on 6/26/2023 when the facility staff (S1) transported R1 to doctor's appointment and left R1 unattended in front of the doctor's clinic. R1 was found alone by R1's Power of Attorney (POA). The incident was reported to the Department via Unusual Incident Report on 7/3/2023.

During today's visit, LPA Rai interviewed ED and Angel Bustos Resident Care Director (RSD). ED stated R1 resides in Memory Care Unit. ED stated S1 did admit mistake of leaving R1 unattended outside the entrance. ED stated the facility's protocol is for facility staff to stay with Memory Care residents until the resident's family meets them at the doctor's clinic/hospital. RSD stated Memory Care residents are assumed to be elopement risk and the residents need to be supervised at all times. ED admitted the facility was at fault for leaving R1 unattended outside of the entrance.

During today's visit, LPA Rai reviewed written statement of S1 of the incident on 6/26/2023 which stated S1 dropped off R1 near the entrance and R1 sat down at the bench and waited for R1's POA. LPA Rai reviewed the Transportation Note for 6/26/2023 for R1 which stated R1 will be met by POA and R1 required transportation to and from the doctor's appointment. Per record review of R1's Functional Needs Assessment on 6/29/2022, R1 has a diagnosis of Dementia. Per record review of R1's care plan, R1 will receive necessary assistance with transportation.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D.
Exit interview was conducted with Executive Director, Ron Ellenich. A copy of this report was provided to Executive Director, Ron Ellenich. Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
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 08/22/2023 03:35 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131


FACILITY NAME: WATERMARK AT ALMADEN, THE
FACILITY NUMBER: 435202775

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/23/2023
Section Cited
CCR
87468.2(a)(4)

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 Additional Personal Rights of Residents in Privately Operated Facilities:(a)... residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in...qualifications, and competency to meet
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Executive Director submit a written plan on understanding regulations and schedule in-services and training to staff by POC date. Executive Director agreed and understood.
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their needs. This requirement was not met as evidenced by: Licensee did not provide care and supervision to meet R1s needs wherein R1 was left unattended in front of the doctor's office which poses an immediate Health, Safety, or Personal Rights risk 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: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 08/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/22/2023
LIC809 (FAS) - (06/04)
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