435202775-12-16-2024-26-AS-KHOS-DCVNZ6-20250113095349

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:39:06 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230614142535

FACILITY NAME:	WATERMARK AT ALMADEN, THE		FACILITY NUMBER:	435202775
ADMINISTRATOR:	ESTRELLADO, JULIE MAY		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(669) 258-4567
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	240	CENSUS:	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:	Executive Director, Corey Miller		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Facility billed resident for services not rendered.
Staff did not adhere to resident's dietary restrictions.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Simi Rai conducted an unannounced visit to conclude the complaint investigation. LPA Rai met with Executive Director, Corey Miller and stated the purpose of today’s visit.

On 6/14/2023 the Department received a complaint with the above allegations. On 6/23/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 3.

Unfounded

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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

LIC9099 (FAS) - (06/04)

Page: 1 of 6

Control Number 26-AS-20230614142535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/16/2024

NARRATIVE

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Page 2 of 3.

Facility billed resident for services not rendered.
It was alleged resident R1 moved out of the facility in 4/30/2023 and was billed for rent and care services in May 2023 and R1 made payment on 9/8/2023.

On 6/23/2023, the Department interviewed 4 staff, including the ED1 that was part of the facility at that time. ED1 stated the facility will bill the month prior, in this case, R1 was billed in April 2023 for May 2023 services. ED1 stated once they receive a 30 -day notice of resident moving out, then they reimbursement the payment from the day the resident moves out from the facility.

Based on review of R1’s Admission Agreement signed on 7/28/2021 by Facility Representative and R1’s Power of Attorney, on page 10 of 44 under “Refund of Prepaid Monthly Fee, “You or your legal representative shall receive the refund on the date you move out of the Community and vacate your Unit…provided you submit a written request to us to receive such refund on that date at least five (5) days before your scheduled move-out date. Otherwise, you or your legal representative shall receive such refund within seven (7) days from the day you leave the Community, and your Unit is vacated.”.

Based on R1’s invoice dated 6/1/2023, payment history is summarized so show R1 was billed for rent and care services on 5/1/2023 but it was reversed, and credit was due to R1. Based on Outgoing Payments Report for R1, R1 was reimbursed the payment on 5/9/2023, 1 day after payment was made on 5/8/2023.

Staff did not adhere to resident’s dietary restrictions.
It was alleged resident R1 physician order resident to be served bite-size food and there were 5 meals that resident was served whole meat servings which were not cut up into bite size.

On 6/23/2023, the Department interviewed 4 staff, including the ED that was part of the facility at that time. Four out of four staff stated the facility staff follow the resident’s physician’s order for diet order and ensure meals are served as order by resident’s physician.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 6

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/14/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230614142535

FACILITY NAME:	WATERMARK AT ALMADEN, THE		FACILITY NUMBER:	435202775
ADMINISTRATOR:	ESTRELLADO, JULIE MAY		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(669) 258-4567
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	240	CENSUS:	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	03:00 PM
MET WITH:			TIME COMPLETED:	04:00 PM

ALLEGATION(S):

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Staff did not assist resident with dental hygiene.
Facility did not follow residents Needs and Services Plan.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

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

LIC9099 (FAS) - (06/04)

Page: 2 of 6

Control Number 26-AS-20230614142535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/16/2024

NARRATIVE

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Page 2 of 3.

Staff did not assist resident with dental hygiene.
It was alleged the staff did not assist resident R1 brushing R1’s teeth before going to bed and in the morning.
On 6/23/2023, the Department interviewed 4 staff, including the ED that was part of the facility at that time. Four out of four staff stated residents are assessed if they are independent or need assistance with ADLs (Activities of Daily Living), which includes dental hygiene assistance. Three out of four staff work directly with R1 and all three staff stated they will remind R1 to brush teeth in the morning and in the evening.

Based on review of 6 of R1’s Functional Needs Assessments from (9/2/2021- 11/16/2022), R1 had a change of condition and on 11/2/2022 and 11/16/2022, it was indicated R1 requires stand-by/remind assistance twice a day where RSA (Resident Service Assistant) will remind resident to brush teeth each morning and evening and ensure the task is complete prior to leaving resident.

Facility did not follow residents Needs and Services Plan.
It was alleged R1’s Needs and Services Plan indicated dental hygiene and diet plan which the facility staff did not follow.

On 6/23/2023, the Department interviewed 4 staff, including the ED that was part of the facility at that time. Three out of four staff work directly with R1 and all three staff stated they will remind R1 to brush teeth in the morning and in the evening and ensure no salt is added to R1’s meals. S3 and S4 stated they will chop up the food when they assess the food item may be difficult for resident to cut themselves. S3 stated they will ask the manager to have the resident’s doctor assess the resident if they observe residents having difficulty with their current dietary needs.

Based on review of R1’s dietary plan on Needs and Service Plan which indicated R1 did not require dietary needs and eating assistance. Based on review of R1’s dental hygiene plan on Needs and Service Plan, R1 requires stand-by/remind assistance twice a day where RSA (Resident Service Assistant) will remind resident to brush teeth each morning and evening and ensure the task is complete prior to leaving resident.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 26-AS-20230614142535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/16/2024

NARRATIVE

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Page 3 of 3.

Based on the interviews conducted with clients and staff and based on observation and records review, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the above allegations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 26-AS-20230614142535

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/16/2024

NARRATIVE

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Page 3 of 3.

Based on review of R1’s Physician’s Report dated 8/4/2021, R1’s special diet was “NAS” which is an abbreviation for “no added salt”. The physician’s report does not indicate the resident was to be served bite-size food. Based on review of R1’s initial Functional Needs Assessments on 07/21/2021 to most recent Functional Needs Assessment 11/16/2022, R1 did not require dietary needs, eating assistance or assistive/adaptive devices. All 6 Functional Needs Assessments were reviewed and signed by R1’s Power of Attorney.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

No deficiencies cited from California Code of Regulations, Title 22. Exit interview conducted with Administrator and a copy of the report was provided.

SUPERVISORS NAME: Romeo Manzano
LICENSING EVALUATOR NAME: Simranjit Rai
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2024

LIC9099 (FAS) - (06/04)

Page: 6 of 6