<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 435202937
Report Date: 03/05/2026
Date Signed: 03/05/2026 10:52:01 AM

Document Has Been Signed on 03/05/2026 10:52 AM - 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 SAN JOSE, THEFACILITY NUMBER:
435202937
ADMINISTRATOR/
DIRECTOR:		KELLIE SHEARERFACILITY TYPE:
740
ADDRESS:1017 S BASCOM AVETELEPHONE:
(520) 797-4000
CITY:SAN JOSESTATE: CAZIP CODE:
95128
CAPACITY: 205CENSUS: 104DATE:
03/05/2026
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Administrator Jolie HigginsTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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 Manuel Monter conducted an unannounced case management- deficiencies , regarding violations discovered during the complaint investigation for 26-AS-20250929092054. LPA met with Administrator Jolie Higgins

Reporting Requirements

During complaint investigation, The Department reviewed R1's progress notes. Progress note dated March 12, 2025 states, R1 is doing well after elopement. R1 did not him/herself, no injuries noted. R1 stated he/she was accompanied by a woman and that all he/she did was push buttons and stepped foot into the elevator. R1 went to receptionist and concierge alerted nurses.

The Department reviewed resident R23 and R24's Progress notes. Progress note dated March 2, 2025 states staff S11, Heard commotion in the hallway. R23 was noted in the hallway in front of apartment door. Two residents were in the hallway being separated by 3 care givers. 1 care giver informed S11 that R24 had a knife and was trying to stab R23. S11 redirected R24 to his/her apartment.

On February 25, 2026. LPA Manuel Monter requested documentation for the incident reports that were sent for the two incidents noted on the progress notes. LPA was informed on February 25, 2026, that the facility does not have documentation for both of these incidents.

Page 1 Out of 2.
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/05/2026
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 4
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)
Page: 2 of 4
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 SAN JOSE, THE
FACILITY NUMBER: 435202937
VISIT DATE: 03/05/2026
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
26
27
28
29
30
31
32
Medication Errors

During complaint investigation, LPA interviewed facility staff regarding medication errors regarding R1’s medication. Interviews with staff revealed potential medication errors, that were not associated with the complaint investigation. At this time, these instances of medication errors are under review and Department will conduct a follow up visit , if warranted.

A technical violation and Deficiency is being cited per California Code of Regulations, Title 22. See LIC809-D. This report was reviewed with Administrator Jolie Higgins and a copy of the report and appeal rights were provided

Page 2 Out of 2. END OF REPORT
NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Manuel Monter
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/05/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2026
LIC809 (FAS) - (06/04)
Page: 3 of 4
Document Has Been Signed on 03/05/2026 10:52 AM - It Cannot Be Edited


Created By: Manuel Monter On 03/05/2026 at 10:23 AM
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
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WATERMARK AT SAN JOSE, THE
FACILITY NUMBER: 435202937

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/05/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/12/2026
Section Cited
CCR
87211(a)(1)

1
2
3
4
5
6
7
87211 Reporting Requirements (a)(1) A written report shall be submitted to the licensing agency … within seven days of the occurrence of any of the events specified in (A) through (D) below… date and nature of event… and disposition of the case. This requirement was not met as evidence by:
1
2
3
4
5
6
7
ADM stated she will send a letter of understanding regarding the regulation.
8
9
10
11
12
13
14
Based on records reviewed and interviews conducted, the facility did not submit a report to licensing regarding the event on 03/12/25 and 3/2/2025. Health and Wellness director confirmed they do not have the reports dated 3/2/25 & 3/12/2025 to provide the Department.
8
9
10
11
12
13
14
(Continue) This poses a potential health, safety or personal rights risk to persons in care.

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:
Manuel Monter
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 03/05/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/05/2026


LIC809 (FAS) - (06/04)
Page: 4 of 4