435202775-4-23-2024-26-AS-SRAI-D4LUBT-20240423152651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202775
Report Date: 04/23/2024
Date Signed: 04/23/2024 03:26:56 PM

Document Has Been Signed on 04/23/2024 03:26 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, THE		FACILITY NUMBER:	435202775
ADMINISTRATOR:	RONALD ELLENICH		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(669) 258-4567
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	240	CENSUS: 112	DATE:	04/23/2024
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Maintainence Director, Wes McKinley		TIME COMPLETED:	03:40 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	Licensing Program Analyst (LPA) Simi Rai conducted an unannounced Case Management visit and met Maintainence Director (MD) Wes McKinley. The purpose of the visit was to conduct a health and wellness check after the facility notified the Department that the facility had two incidents on 4/14/2024 and 4/22/2024 wherein the facility was out of power. Per LIC 624 Unusual Incident/Injury Report for incident dated 4/14/2024, at 6am a surge of power caused a building wide power outage and by 11:45am a power generator was installed to resume power for the facility. Per report, the facility was able to run normal operations. Per LIC 624 Unusual Incident/Injury Report for incident dated 4/22/2024 at 12:24pm, the generator had low fuel which caused a power outage and power was restored at 1:23pm. Per report, the facility was able to run normal operations. During visit, LPA Rai observed the outside area, behind the facility were the power surge occurred and the area was fenced off. LPA Rai observed the power generator providing power to the facility. MD stated the electrical team is currently investigating the cause of the power outage and the facility is able to function with the generator. MD stated during the two incidents, there were no issues with the water temperatures and room temperatures. Operations were able to run as normal. LPA observed the medication room and staff are able to administer medications to residents. The facility has internet access. LPA Rai interviewed Angel Bustos, Resident Services Director (RSD). RSD stated during the two incidents, there were no issues with medication administration. Hospice agency was notified for 1 resident under Hospice services. RSD stated there are 3 residents that require oxygen administration and oxygen tanks are available for emergency. RSD stated there were no hospitalization caused by the two power outage incidents. Continue LIC 809-C, Page 1 of 2.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

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 2

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: 04/23/2024

NARRATIVE

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LPA toured the facility kitchen and observed emergency food and water supplies. LPA observed freezer and fridge in working condition and observed 2 days of perishable foods and 7 days of non perishable foods. LPA Rai observed the emergency food supply and water supply. LPA Rai interviewed Debbie Teixiera, Dining Service Director (DSD). DSD stated the power outage did not cause a disruption in meals served to the residents and there was a food truck on stand by to provide food for residents.

LPA observed 3 resident rooms and water temperature and room temperature was within range.

The facility will provide an update on when repairs will be made and where facility will no longer need power generator and the facility's power will go online.

No deficiencies were cited at this time as per California Code of Regulations Title 22. This report was reviewed with Maintainence Director, Wes McKinley and a copy of this report was provided.

SUPERVISOR'S NAME: Romeo Manzano	TELEPHONE: (650) 388-2297
LICENSING EVALUATOR NAME: Simranjit Rai	TELEPHONE: (408) 324-2112
LICENSING EVALUATOR SIGNATURE:	DATE: 04/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/23/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2