435202775-12-16-2024-26-AS-KHOS-DCVPGE-20250113101814

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:47:51 PM

Unsubstantiated

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
09/07/2023 and conducted by Evaluator Simranjit Rai

COMPLAINT CONTROL NUMBER: 26-AS-20230907100701

FACILITY NAME:	WATERMARK AT ALMADEN, THE		FACILITY NUMBER:	435202775
ADMINISTRATOR:	RONALD ELLENICH		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(669) 258-4567
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY:	240	CENSUS: 147	DATE:	12/16/2024
		UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Executive Director, Corey Miller		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Facility staff does not check resident for incontience care.
Facility staff forgot to serve a meal to resident.
Resident was wearing the same clothing for at least 24 hours.
Facility did not provide snacks prior to supplemental fee for snacks.
Facility did not ensure resident safety, resulting in resident sustaining an injury.
Facility does not have adequate staffing to meet the resident's needs.

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 9/7/2023, the Department received a complaint with the above allegations. On 9/14/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 5.

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: 1 of 5

Control Number 26-AS-20230907100701

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 5.

Facility does not check resident for incontinence care.

It was alleged the resident’s undergarments were not changed for more than 6 hours while resident had visitors and resident was on 2-hour status checks for incontinence care.

On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. S1 stated the facility staff do hourly check on all residents to check on the status of the resident, including if the resident requires incontinence care. Two out of two staff stated R1 requires incontinence care and R2’s incontinence products are changed every 2 hours as necessary.

On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation.

Based on review of R1’s Care Plan dated 1/20/2023, R1 needed assistance with incontinence care wherein used products would need to be disposed every shift. Based on review of R1’s Functional Needs Assessment dated 11/24/2021, R1 needs assistance in the morning and night to change the hygiene pad.

Facility staff forgot to serve a meal to resident.

It was alleged the resident was not served a meal while resident had a visitor from 3pm-9pm. It was alleged when facility staff was asked about serving the meal to resident, they stated they forgot to give the resident the meal.

On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. S1 stated R1 needs assistance with meals. S1 stated the facility staff monitor residents who receive meals in their rooms and resident was provided a meal tray during dinner service. Two out of two staff stated they track R1’s food service when food tray was provided to R1.

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: 2 of 5

Control Number 26-AS-20230907100701

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 5.

Based on review of R1’s meal tray tracker, the staff noted R1 required meal tray service during dinner time on 9/5/2023. Based on progress notes for R1 from 9/6/2023 – 9/11/2023, staff recorded providing incontinence care to R1 at least once per shift.

On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation.

Resident was wearing the same clothing for at least 24 hours.

It was alleged the facility staff did not change a resident’s clothes wherein resident was wearing the same clothes two days in a row.

On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. S1 stated R1 has night gowns and staff change R1 in bed. S1 is not aware why R1 was not changed in the evening. S3 stated R1 is not changed when R1’s clothes are clean. S3 stated R1 does not refuse to be changed, so there shouldn’t be a reason why R1 was not changed.

On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation.

Facility did not provide snacks prior to supplemental fee for snacks.

On 9/14/2023, the Department interviewed the Administrator (ADM) who was in charge of the facility during the time of the complaint. ADM stated the facility changed its billing system when the new partnership took effect. ADM stated the facility is not charging extra for snacks and it has always been included in the meals.

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 5

Control Number 26-AS-20230907100701

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 4 of 5.

On 9/14/2023, the Department interviewed three staff (S1-S3). Three out of three staff stated the staff provide snacks to the residents and there are snacks available to residents at all times which include granola bars, graham crackers, and cookies. Three out of three staff stated the facility staff have always provided snacks to the residents.

On 12/16/2024, LPA Rai interviewed at random 3 residents residing in Memory Care unit when this complaint was initially received by the Department. Two out of three residents refused to be interviewed. One out of three residents were not able to answer LPA’s questions related to this complaint investigation.

Facility did not ensure resident safety, resulting in resident sustaining an injury.

It was alleged resident sustained bruises due to impact and resident is bedridden and cannot move hands or head.

On 9/14/2023, the Department interviewed the Administrator (ADM) who was in charge of the facility during the time of the complaint. ADM stated the resident has unknown behaviors which may have contributed to the injury.

On 9/14/2023, the Department interviewed two staff (S1&S3) who provides care and supervision to R1. Two of two staff stated he/she is not aware of R1’s bruises. S1 stated R1 will move around in the bed so staff including S1 place blankets and pillows around R1’s head and hands, so R1 does not sustain bruising from the half-bed rails. Two out of two staff stated they did not see or hear staff physically hurt R1.

Based on review of R1’s Care Plan dated 1/20/2023, R1’s skin assessment is not provided wherein skin issues are not documents. Based on review of R1’s Functional Needs Assessment dated 11/24/2021, R1’s skin assessment and/or skin issues were not documented.

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 5

Control Number 26-AS-20230907100701

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 5 of 5.

Facility does not have adequate staff facility to meet the resident’s needs.

It was alleged the facility is short staffed and they do not have enough staff in the building.

On 9/14/2023, the Department interviewed the Administrator (ADM) who was in charge of the facility during the time of the complaint. ADM stated the facility staffing is set according to the needs and assessment of the residents. ADM stated resident (R1) is the only resident in Memory Care that needs 2-person assistance, and they have enough staff in the building to provide the resident’s needs.

On 9/14/2023, the Department interviewed three staff (S1-S3). S1 stated the facility has enough staff, but the staff communicating to management about resident’s changing needs so the assessment can reflect the resident’s needs. S1 stated the staff need to ensure the assessment correctly reflects the needs of the resident, so management can ensure this is adequate staffing at the facility. S3 stated there have been once or twice he/she recalls when there was one care staff during nocturnal (NOC) shift but there is always one Med-Tech to assist the care staff during NOC shift.

Based on review of staff schedule for Memory Care unit from July 2023 - September 2023, there is at least 2-3 care staff and 1 Medication Technician present during each shift for morning shift (6am – 2pm), 2 – 3 care staff and 1 Medication Technician present during each shift for afternoon shift (2pm – 10pm), and 1 -2 care staff and 1 Medication Technician present during nocturnal (NOC) shift (10pm-6am).

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 Executive Director, Corey Miller 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)

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