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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202775
Report Date: 01/11/2024
Date Signed: 01/11/2024 06:23:28 PM


Document Has Been Signed on 01/11/2024 06:23 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:RONALD ELLENICHFACILITY TYPE:
740
ADDRESS:4610 ALMADEN EXPRESSWAYTELEPHONE:
(669) 258-4567
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:240CENSUS: 118DATE:
01/11/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Angel Bustos, Resident Service Director and Patty Cuzia, Regional Director of Health Services.TIME COMPLETED:
06:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Simi Rai arrived unannounced to conduct a continuation of the annual inspection from 1/9/2024 and met with Interim Executive Director, Brenda Ritter. LPA Rai continued the annual inspection with Angel Bustos, Resident Service Director and Patty Cuzia (RDH) Regional Director of Health Services.

LPA Rai toured the kitchen and dining room. LPA Rai observed 2 days of perishable food supply and 7 days of non-perishable food supply. LPA Rai observed a delivery of water gallons during visit and facility had water supply in the pantry, emergency supply closet and kitchen. LPA Rai observed daily temperature log of refrigerator and freezer.

During visit, LPA Rai continued to review 5 resident files. LPA Rai observed 5 out of 5 resident files not including weight log. Resident Services Director (RSD) Angel Bustos stated the resident files do not have weight log and the staff are not monitoring Assisting Living resident's weight at this time. RSD stated the facility did order and received a weight machine which will accommodate a wheelchair therefore the facility will initiate weight log for Assisted Living residents.

RSD stated the facility recently took over as managing group from the previous managing group and the current facility will honor all Admission Agreements signed by residents and resident's families from the previous managing group. RDH stated the new residents signing under the facility will have new admission agreements reflecting the name of the facility.

During a random review/audit of Assisted Living resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with RSD and Resident Care Coordinator (RCC) counted the tablets from the medication bottles, 4 out of 4 medications prescribed to R1 was given as prescribed by the doctor, but the medication count was not correct.
Continuation on LIC 809-C, Page 1 of 3.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:
DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6


Document Has Been Signed on 01/11/2024 06:23 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
CCR
87465(h)(6)

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87465 Incidental Medical and Dental Care
(h)(6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes:
This requirement is not met as evidenced by:
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RSD stated the facility will conduct a mandatory in-service with all staff administering medications and plan of action is submitted by POC due date.
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Based on record review and interview, R1-R2's records of centrally stored medication were inaccurate which poses/posed a potential health, safety or personal rights risk to persons in care.
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Type B
01/18/2024
Section Cited
CCR87466

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87466 Observation of the Resident
...When changes such as unusual weight gains or losses ... are observed, the licensee shall ensure that such changes are documented...
This requirement is not met as evidenced by:
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RSD stated the facility will initiate weight log with new weight scale which accommadates residents with wheelchair and plan of action is submitted by POC due date.
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Based on record review, LPA did not observe weight log in residents' file in Assisted Living, RSD stated the staff do not observe resident's weight which poses/posed a potential 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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6


Document Has Been Signed on 01/11/2024 06:23 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/12/2024
Section Cited
CCR
87303(e)(2)

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87303 Maintenance and Operation (e)(2) ...Hot water temperature controls shall be maintained ... the temperature of hot water used by residents to attain a temperature of not less than 105 degree F and not more than 120 degree F.
This requirement is not met as evidenced by:
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RDH stated Maintenance Director will follow up with water temperatures in resident rooms to ensure it is within regulation and plan of action will be submitted by POC due date.
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Based on observation, LPA observed 9 out of 9 resident bathroom sinks with hot water temperatures ranging from 120.9F - 130.3F which poses/posed an immediate health, safety or personal rights risk to persons in care.
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Type A
01/12/2024
Section Cited
CCR87468.1(a)(2)

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87468.1 Personal Rights of Residents in All Facilities (a)(2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment.
This requirement was not met as evidenced by:
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RDH stated the staff should not lock common bathroom and resident rooms and staff training will be provided and plan of action will be submitted by POC due date.
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Based on interview and record review, IED and RSA stated the bedrooms and bathrooms were locked in the Memory Care Department and residents needs to ask staff to open the doors which poses/posed an immediate health, safety or personal rights risks 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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 01/11/2024 06:23 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: 01/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/18/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia (c)(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment...

This requirement is not met as evidenced by:
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RSD stated R2's physician has been faxed in November 2023 and staff faxed the physician again today 1/11/2024. RSD will submit a plan of action by POC due date.
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Based on record review of R2's file, R2 did not have an updated annual medical assessment which poses/posed a potential 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: 01/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


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
VISIT DATE: 01/11/2024
NARRATIVE
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Page 2 of 3.

During a random review/audit of Memory Care resident's medication bottle and LIC 622 Centrally Stored Medication and Destruction Record. LPA Rai along with RSD and RCC counted the tablets from the medication bottles, 7 out of 8 medications prescribed to R2 was given as prescribed by the doctor, but the medication count was not correct. LPA Rai reviewed R2's medical assessment which was conducted on 12/2/2022 and the facility did not have an annual medical assessment on file as R2 has a Dementia diagnosis. RSD stated they were aware in November 2023 of R2 missing annual medical assessment but have not received a medical assessment from R2's physician.

During interview with Staff 1 and Staff 2, 2 staff stated residents are given medications prescribed by physician which was reflected on R1-R2's electronic Medication Administration Record (MAR), but the staff do not log the destruction of medication, therefore the count of the medications is not accurate. RSD stated the facility staff will conduct a mandatory in-service to train the staff of medication administration, including accurate record keeping.

On 1/9/2024, LPA Rai observed the water temperatures of the resident bathroom sinks in Memory Care and Assisted Living rooms. 9 out of 9 resident bathroom sinks water temperatures ranged from 120.9F - 130.3 F, which is higher than as stated in regulation where the water temperatures for personal use shall be between 105F-120F. IED stated the water heater was not affected during the power outage and the facility continued to have hot water.

During visit, LPA Rai observed the common bathrooms located in the Memory Care unit were locked. LPA Rai observed the resident bedrooms located in Memory Care unit were locked. RSA stated resident would use the bathroom and throw excess toilet paper in the bathroom and clog the toilet. RSA stated the resident would go into other resident's bedrooms. RSD and RDH were present during conversation. RDH informed LPA Rai the facility does not have a policy stating the common bathrooms and resident bedrooms in Memory Care unit shall be locked and RDH will ensure the facility staff are not locking the common bathrooms and resident rooms in Memory Care unit. RSD, RDH, RCC and Memory Care Director, Leann Marquez agreed and understood the facility shall not lock the common bathrooms and resident rooms to substitute staff supervision in Memory Care unit.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6
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
VISIT DATE: 01/11/2024
NARRATIVE
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Page 3 of 3.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 809-D. Technical Violation was provided.

Exit interview was conducted with Angel Bustos, Resident Service Director and Patty Cuzia (RDH) Regional Director of Health Services and agreed and understood the report. A copy of this report and Appeal Rights were provided.
SUPERVISOR'S NAME: Romeo ManzanoTELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit RaiTELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6