Inspection Reports for
The Watermark at San Ramon

The complaint investigation was substantiated for allegations related to inadequate resident hygiene, grooming, bedding cleanliness, incident reporting, and diabetic care. The investigation found evidence through interviews, observations, disciplinary records, and documentation. Other allegations related to feeding, hydration, food contamination, and resident aggression were unsubstantiated due to lack of evidence.

The investigation substantiated allegations that staff failed to consistently shower residents, assist with dressing, maintain clean bedding, properly report incidents, and meet diabetic needs. Unsubstantiated allegations included failure to feed residents, ensure adequate hydration, prevent food contamination by ants, and prevent resident-to-resident aggression. Deficiencies were documented with disciplinary actions and in-service trainings conducted.

The visit was complaint-related, involving the delivery of an amended complaint report due to missing information in the prior report dated 12/30/2024.

The Licensing Program Analyst delivered the amended complaint report and related documents, conducted an exit interview, and provided a copy of the reports to the facility representative.

The complaint investigation was substantiated. Allegations included a resident suffering a fall resulting in hospitalization, staff not safeguarding the resident's personal items, and staff not following physician's instructions. The investigation included interviews, record reviews, and observations confirming these issues.

The investigation substantiated all allegations: the resident experienced multiple falls leading to hospitalization due to inconsistent enforcement of fall prevention measures; staff failed to properly safeguard the resident's personal belongings due to procedural lapses and staffing issues; and staff did not consistently follow the physician's instructions regarding the resident's care plan, increasing fall risk. An immediate civil penalty of $500 was assessed.

The Licensing Program Analyst toured the facility and reviewed staff and resident records. No deficiencies were cited during the visit.

The initial complaint investigation was conducted on 2024-08-08 under the wrong complaint number and was later amended to the correct complaint number 15-AS-20240729122132. The visit on 2024-08-13 was a follow-up case management visit related to this complaint.

No deficiencies were cited during the visit. The Licensing Program Analyst met with facility staff and provided copies of amended and correct complaint reports.

The complaint investigation was substantiated for the allegation that staff did not provide medical attention to a resident. The preponderance of evidence standard was met based on interviews and record review. Other allegations were unsubstantiated due to lack of evidence.

The investigation found the allegation that staff did not provide proper medical attention to a resident to be substantiated due to failure to complete a thorough assessment, resulting in missed minor injuries posing a potential safety risk. Other allegations regarding medication mismanagement, supervision, and prevention of residents entering other rooms were unsubstantiated.

The facility was toured and observed to be clean and in good repair with residents appearing safe. No imminent health or safety concerns were noted and no deficiencies were cited during this visit.

The visit was triggered by a priority 2 complaint. No deficiencies were found, and the complaint was not substantiated.

The Licensing Program Analyst toured the facility including bedrooms, bathrooms, common areas, kitchen, and outdoor area. No deficiencies were cited during the visit; all safety and health measures such as temperature controls, medication storage, fire safety equipment, and food supplies were found to be adequate.

The complaint was substantiated. Staff S1 was found to have financially abused resident R1 by accepting gifts and facilitating purchases for personal use.

The investigation found that staff S1 financially abused resident R1 by accepting gifts and facilitating purchases for personal benefit, including airline tickets and clothing items. The facility took disciplinary action against S1.

The visit was triggered by a complaint (CN# 15-AS-20220817112257).

The inspection found that personnel records for three staff members (S1, S2, and S3) were incomplete, lacking application and contact information, and missing termination date and reason for termination for one staff member (S2). This deficiency poses potential health, safety, and personal rights risks to persons in care.

The complaint investigation was substantiated for allegations that the resident sustained a fracture while in care, the facility failed to meet reporting requirements, and the resident's care plan was inaccurate. Another complaint regarding multiple injuries and failure to follow physician orders was unsubstantiated.

The investigation substantiated that a resident sustained a fracture while in care and that the facility failed to report the incident as required. Additionally, the resident's care plan inaccurately indicated the use of an assistive device which the resident did not require. Another set of allegations regarding multiple injuries and failure to follow physician orders was unsubstantiated due to lack of preponderance of evidence.

The inspection found deficiencies including staff not having received required first aid training and loose medication found in a resident's kitchen cabinet. The Executive Director agreed to provide training and removed the medication during the visit.

The complaint was unsubstantiated as there was no preponderance of evidence to prove the alleged violations occurred.

The investigation found that key fobs were only provided to staff for access to memory care units, and families were instructed to call the front desk for after-hours access. There was no evidence of retaliation against any authorized representatives. The complaint was unsubstantiated.

The complaint investigation was initiated based on allegations received on 02/16/2023 regarding removal of licensing and Ombudsman posters and blocking of door entrances with chairs. The allegations were substantiated after observations, interviews, and record reviews.

The investigation substantiated the allegations that the facility did not post the Ombudsman poster in the lobby as required and that two chairs were blocking an exit door in the Memory Care unit, posing potential health, safety, and personal rights risks to residents.

The inspection found that the facility generally maintained proper infection control practices including PPE use, hand hygiene, and screening procedures. However, two deficiencies were observed involving unlocked hazardous items accessible to a resident with dementia, which were corrected during the visit. Additionally, staff health screening documentation was incomplete for some employees.

Inspection was triggered by a priority 2 complaint. No imminent health or safety concerns were identified during the inspection.

The facility was toured and inspected including apartments, bathrooms, common areas, kitchen, and outdoor area. No imminent health or safety concerns were found; hot water temperature, food supplies, refrigerator temperature, medication storage, smoke detectors, carbon monoxide detector, and fire extinguisher were all found to be in compliance.

Inspection was triggered by a priority 1 complaint. No deficiencies were found and the complaint was not substantiated.

The facility was toured and inspected with no imminent health or safety concerns observed. Hot water temperature, food supplies, refrigerator temperature, medication security, smoke detectors, carbon monoxide detector, fire extinguisher, and passageways were all found to be in compliance. No deficiencies were cited during the visit.

The facility was toured including multiple areas and observed to have proper infection control measures in place such as PPE use, screening, and hygiene supplies. No deficiencies were cited during the visit.