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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 019200874
Report Date: 03/24/2025
Date Signed: 03/24/2025 11:38:33 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20221212154158
FACILITY NAME:WATERMARK BY THE BAY, THEFACILITY NUMBER:
019200874
ADMINISTRATOR:HALL, STEPHANIE JFACILITY TYPE:
740
ADDRESS:1440 40TH STREETTELEPHONE:
(510) 594-8800
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY:175CENSUS: 78DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:JoNai Davis- Hendricks, Human Resources CoordinatorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff did not seek medical attention in a timely manner.
INVESTIGATION FINDINGS:
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On 3/24/2025 at 10:40 a.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Human Resources Coordinator, JoNai Davis- Hendricks explained the purpose of the visit. LPA received verbal authorization from Executive Director (ED), Stephanie Hall for JoNai to sign the report. ED was not available during the visit.

Report Continue on LIC9099c...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
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 7
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
This is an official report of an unannounced visit/investigation of a complaint received in our office on
12/12/2022 and conducted by Evaluator Kelly Nguyen
COMPLAINT CONTROL NUMBER: 15-AS-20221212154158

FACILITY NAME:WATERMARK BY THE BAY, THEFACILITY NUMBER:
019200874
ADMINISTRATOR:HALL, STEPHANIE JFACILITY TYPE:
740
ADDRESS:1440 40TH STREETTELEPHONE:
(510) 594-8800
CITY:EMERYVILLESTATE: CAZIP CODE:
94608
CAPACITY:175CENSUS: 78DATE:
03/24/2025
UNANNOUNCEDTIME BEGAN:
10:49 AM
MET WITH:JoNai Davis- Hendricks, Human Resources CoordinatorTIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Questionable death.
Resident sustained injuries while in care.
Facility did not provide resident's records to responsible party.
INVESTIGATION FINDINGS:
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On 3/24/2025 at 10:40 a.m. Licensing Program Analyst (LPA) K. Nguyen conducted an unannounced visit to deliver the findings for the above complaint allegations. LPA met with Human Resources Coordinator, JoNai Davis- Hendricks explained the purpose of the visit. LPA received verbal authorization from Executive Director (ED), Stephanie Hall for JoNai to sign the report. ED was not available during the visit.

Allegation: Questionable death: Unsubstantiated

On 3/15/2023, The department reviewed record of R1 including medical record, discharge summary, death report and progress notes indicated R1 was admitted into the Alta Bates Summit Medical Center on 11/6/2020 and discharged on 11/8/2020.

Report Continue on LIC 9099c...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
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 7
Control Number 15-AS-20221212154158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERMARK BY THE BAY, THE
FACILITY NUMBER: 019200874
VISIT DATE: 03/24/2025
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R1 was diagnosed with nontraumatic intracranial hemorrhage, hypertension, macrocytic anemia, history of Cerebrovascular Accident (CVA), dementia and seizure. However, R1 death certificate indicated her causes of death were cardiopulmonary arrest, myocardial infarction and hypertension. There were no other contributing factors to R1 death. A manner of death was not indicated.

Allegation: Resident sustained injuries while in care: Unsubstantiated



On 3/15/2023, The department reviewed record of R1 care notes and interview RP, and staffs indicate that R1 was sent to the hospital for evaluation.

RP stated “While coming on to a Zoom meeting with Verna on 10/27/2020, RP daughter noticed and obvious bruise under R1 right eye. Staff did not report anything to R1 daughter prior to the Zoom meeting and did not know how R1 sustained the bruise”. During staff interviews, caregivers and med techs recalled R1 having a bruise, but vaguely recalled what happened after it was observed. Staff did not know how R1 sustained the bruise. Depending on the severity of an injury, residents are sent out to the hospital for further evaluation. Staff stated family members can always decline to have the resident transported to the hospital. During R1 hospitalization, R1 was diagnosed with a nontraumatic intracranial hemorrhage, dementia and seizure.


Report Continue on LIC 9099c...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 7
Control Number 15-AS-20221212154158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERMARK BY THE BAY, THE
FACILITY NUMBER: 019200874
VISIT DATE: 03/24/2025
NARRATIVE
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Allegation: Facility did not provide resident's records to responsible party. Unsubstantiated

On 3/15/2023, The department interview R1 daughter indicated that recorded requested for R1 medical records and R1 file are all on the text messages that are being submitted to CCLD department. The department reviewed record of R1 daughter text messages, but didn’t not find that either R1 medical record and R1 files was being requested. However, there was a request of x-ray being requested by R1 daughter.

Based on interviews and record reviews conducted, the above allegations are unsubstantiated.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are unsubstantiated.

Exit interview was conducted and a copy of this report was provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 7
Control Number 15-AS-20221212154158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERMARK BY THE BAY, THE
FACILITY NUMBER: 019200874
VISIT DATE: 03/24/2025
NARRATIVE
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Allegation: Staff did not seek medical attention in a timely manner- Substantiated

On 3/15/2023, The department reviewed record of R1 including medical record, care note, facility’s protocol, and interview staff. The facility's protocol for residents sustaining a fall or an injury, if severe enough, are automatically sent out to the hospital for an evaluation. Because memory care residents are unable to verbalize whether they have fallen, in pain or injured themselves, there could be underlying issues after they sustained a fall or injury that cannot be seen with the naked eye. Despite the decision to transport the resident to the hospital, their families or responsible party can always decline medical transport. Caregiver recalled seeing R1 bruise and reporting it to the med tech. Caregiver was not positive, but believed R1 was sent to the hospital two days later to have it looked at. Program Director did not recall R1 bruise. After being shown photos of it, Program director confirmed that it was definitely a bruise and staff should have immediately sent R1 to the hospital to be evaluated. Caregiver remembered seeing the bruise on R1 eye and reported it to the med techs, but she did not know what was done after the fact.

Report Continue on LIC 9099c...

SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 7
Control Number 15-AS-20221212154158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME: WATERMARK BY THE BAY, THE
FACILITY NUMBER: 019200874
VISIT DATE: 03/24/2025
NARRATIVE
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According to text messages between R1 daughter and the second-floor med tech (names unknown) between 10/28/2020 through 10/31/2020, the med tech was told to send R1 to the Emergency Department (ED) if the bruise worsened, per R1 doctor, Dr. Artemio Perez. On 10/29/2020, the med tech on duty advised they would send R1 out to the ED or request an x-ray if the bruise worsened. Dr. Perez ordered x-rays to be done, but it did not appear they were as R1 daughter inquired about it and there was no response by staff via text message. There were no records of an x-ray done and R1 did not go to the ER until 11/6/2020, approximately 10 days after the bruise was first observed.


Based on evidence obtained during the course of this investigation, the Department has substantiated staff did not seek medical attention in timely manner. This is a factual determination based on all the facts and circumstances of the case. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 6 of 7
Control Number 15-AS-20221212154158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: WATERMARK BY THE BAY, THE
FACILITY NUMBER: 019200874
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/24/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/04/2025
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care
(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).


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By POC due date, ED agreed to complete and submit to CCL in-service staff retraining certifications on full understanding of the regulation 87465(g) Incidental Medical and Dental Care section (g) in compliance with Title 22 Section 87465(g).
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This requirement was not met as evidenced by staff there were no records of an x-ray done and R1 did not go to the ER until 11/6/2020, approximately 10 days after the bruise was first observed, which posed a potential health & safety risk to resident in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Kelly Nguyen
LICENSING EVALUATOR SIGNATURE:

DATE: 03/24/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2025
LIC9099 (FAS) - (06/04)
Page: 7 of 7