079200962-11-8-2023-15-AS-AGOZ-CXE2DH-20231108161821

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 079200962
Report Date: 11/08/2023
Date Signed: 11/08/2023 04:20:43 PM

Document Has Been Signed on 11/08/2023 04:20 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME:	WATERMARK AT SAN RAMON, THE		FACILITY NUMBER:	079200962
ADMINISTRATOR:	HARRISON, NANCY		FACILITY TYPE:	740
ADDRESS:	12720 ALCOSTA BLVD		TELEPHONE:	(925) 725-1485
CITY:	SAN RAMON	STATE: CA	ZIP CODE:	94583
CAPACITY:	95	CENSUS:	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Executive Director		TIME COMPLETED:	04:30 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) A. Gomez and Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a 1-Year Annual Required visit on this date starting at 9:35am. LPA and AGPA met with Executive Director (ED), Kiel Stromgren and Resident Care Director, Ashley Paris. LPA toured facility with ED including but not limited to random resident's bedrooms, bathrooms, kitchen, common area, and outdoor area. There are no bodies of water observed. Indoor and outdoor passageways are kept free of obstruction. Room temperature in the hallway is maintained at 72 degrees F. Hot water temperature in random residents’ bathroom is maintained at 112.9, and 108.7 degrees F. Random resident's bathrooms were equipped with grab bars and non-skid mats. Hygiene supplies were available for residents. There is a minimum of one week supply of non-perishable and 2-day perishable foods. Refrigerator temperature was maintained at 41 degrees F and freezer temperature was maintained below 0 degrees F. Smoke detectors are interconnected with sprinklers and observed throughout the facility. Fire extinguisher was last serviced on 11/01/2023. Fire and Earthquake Drill was last conducted on 10/24/2023. Emergency Disaster Plan was last posted on 11/08/2023. LPA reviewed 5 staff records. 5 of 5 staff are associated. LPA reviewed 5 resident records and 5 of 5 residents have current Medical Assessment on file. LPA reviewed a sample of resident's medications. Continued on LIC 809-C

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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 11/08/2023 04:20 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK AT SAN RAMON, THE	FACILITY NUMBER: 079200962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87411(C)(1)

87411 Personnel Requirements - General (c) All RCFE staff who assist residents with personal activities of daily living shall receive initial and annual training as specified in Health and Safety Code sections 1569.625 and 1569.69(1) Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above by All RCFE staff who assist residents with personal activities of daily living not having receive appropriate training in first aid from persons qualified which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/20/2023
	Plan of Correction
1 2 3 4	By POC date Executive Director agrees to provide First Aid training and certify the required care staff and submit proof of certifications to CCLD

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 11/08/2023 04:20 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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK AT SAN RAMON, THE	FACILITY NUMBER: 079200962
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 11/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87465(h)(2)

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored:(2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above by R6 having loose Ibuprofen in top right side kitchen cabinet when the physicians report for R6 states that R6 can not manage own medication which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 11/09/2023
	Plan of Correction
1 2 3 4	Executive Director removed medication during visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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
OAKLAND ASC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK AT SAN RAMON, THE	FACILITY NUMBER: 079200962
	VISIT DATE: 11/08/2023

NARRATIVE

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The following deficiencies were observed during visit:

LPA and AGPA observed loose Ibuprofen in R6's Kitchen cabinet
LPA and AGPA observed missing first aid for required staff during record review

Please submit the following documents to CCLD by 11/20/2023

Copy of Liability Insurance

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct these deficiencies and/or repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted and appeal rights provided

SUPERVISOR'S NAME: Yvonne Flores-Larios	TELEPHONE: (510) -28-0517
LICENSING EVALUATOR NAME: Alona Gomez	TELEPHONE: 510-239-1306
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

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