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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 435202775
Report Date: 12/16/2024
Date Signed: 12/16/2024 05:58:18 PM

Unfounded


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
12/07/2023 and conducted by Evaluator Simranjit Rai
COMPLAINT CONTROL NUMBER: 26-AS-20231207104032
FACILITY NAME:WATERMARK AT ALMADEN, THEFACILITY NUMBER:
435202775
ADMINISTRATOR:RONALD ELLENICHFACILITY TYPE:
740
ADDRESS:4610 ALMADEN EXPRESSWAYTELEPHONE:
(669) 258-4567
CITY:SAN JOSESTATE: CAZIP CODE:
95118
CAPACITY:240CENSUS: 147DATE:
12/16/2024
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Executive Director, Corey MillerTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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1. Residents in care sustained unexplained skin injuries
2. Residents in care sustained multiple falls while in care
3. Staff did not ensure resident's room was kept free of hazards
4. Staff did not safeguard resident's personal clothing items
5. Staff leave medications unattended at the reach of residents in care
6. Residents in care are not provided activities/ 7.Staff forgot to serve meals to residents in care
8. Snacks were not made available to residents in care
9. Staff do not ensure passageways are kept free of obstructions
10. Staff were not present at the facility during their night time shift
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 12/7/2023, the Department received a complaint with the above allegations. On 12/15/2023, the Department conducted an initial investigation at the facility.

Continuation on LIC 9099-C, Page 1 of 8.
Unfounded
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 8
Control Number 26-AS-20231207104032
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 8.
Residents in care sustained unexplained skin injured.
It was alleged an unidentified resident sustained a questionable skin injury during an unknown date and time.
On 12/15/2023, LPA Rai interview two staff (S1-S2). Two out of two staff stated they did not have knowledge of a resident who sustained a skin injury in the past three months. Two out of two staff stated the staff will submit Incident Reports for any injuries sustained to the residents.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated did not have knowledge of a resident who sustained a skin injury during October 2023 – December 2023.

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.

On 12/16/2024, LPA Rai reviewed at random 3 resident files. LPA Rai reviewed R1-R3’s Physician’s Reports, Appraisal/Needs and Services Plan and Progress Notes. LPA Rai did not observe any note stating resident sustained a skin injury.

Based on review of Incident Reports received from October 2023 - December 2023, LPA Rai reviewed 20 Incident Reports and 0 out of 20 reports were related to resident sustaining a questionable skin injury.

Residents in care sustained multiple falls while in care.
It was alleged an unidentified resident had multiple falls at the facility which led to hospitalization during an unknown date and time.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident having multiple falls which lead to hospitalization. Two out of the two staff stated the staff will submit Incident Reports for any injuries sustained to the residents.
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 8
Control Number 26-AS-20231207104032
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 8.
On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of a resident having multiple falls which lead to hospitalization. Three of three staff cannot recall any incidents which caused resident to go to the hospital.

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.

On 12/16/2024, LPA Rai reviewed at random 3 resident files. LPA Rai reviewed R1-R3’s Physician’s Reports, Appraisal/Needs and Services Plan and Progress Notes. LPA Rai did not observe any note stating resident sustained an injury after having multiple falls.

Based on review of Incident Reports received from October 2023 – December 2023, LPA Rai reviewed 20 incident Reports and 3 out of 20 reports were related to resident being hospitalized. Out of the 3 reports, 0 reports were related to hospitalized due to repeated falls.

Staff did not ensure resident’s room was kept free of hazards.
It was alleged an unidentified resident had a broken vase in the room and the facility staff did not remove the pieces of glass during an unknown date and time.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident’s room was not kept free of hazards. Two out of the two staff stated the staff will submit work order if the resident’s room need to be cleaned of hazards. S1 reviewed work orders placed from October 2023 – December 2023 and they were not related to issues related to cleaning a broken vase in resident’s room.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Two out of three staff stated they did not have knowledge of a resident’s room had a broken vase. S3 stated he/she remembers an incident with a broken vase but is not sure which resident it involved and if staff removed the broken case from the room in a timely manner.
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 8
Control Number 26-AS-20231207104032
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 8.
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.

Staff did not safeguard resident’s personal clothing items.
It was alleged an unidentified resident had incontinence products still attached to the clothing placed in the laundry.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident’s incontinence products attached to resident’s clothing placed in laundry.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Two out of three staff stated they did not have knowledge of resident’s incontinence products attached to resident’s clothing placed in laundry. S3 stated he/she is aware of issues wherein residents would confuse the waste basket and the laundry basket, but S3 has not seen or heard staff place incontinence products still attached to the clothing in the laundry. Three of three staff stated they have not seen or heard staff place incontinence products still attached to the clothing in the laundry.

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.

Staff leave medications unattended at the reach of residents in care.
It was alleged an unidentified resident’s medications were left in the resident’s room during an unknown date and time.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident’s medications were left in resident’s room unattended. Two out of the two staff stated they have no heard or seen staff leave medications in resident’s room unattended.
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 8
Control Number 26-AS-20231207104032
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 8.
On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of resident’s medications were left in resident’s room unattended. Three out of the three staff stated they have no heard or seen staff leave medications in resident’s room unattended.

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.

Residents in care are not provided activities.
It was alleged facility staff were not conducting activities in the activity room.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of resident having multiple falls which lead to hospitalization. Two out of the two staff stated the staff will submit Incident Reports for any injuries sustained to the residents.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of a resident having multiple falls which lead to hospitalization. Three of three staff cannot recall any incidents which caused resident to go to the hospital.


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 activity calendar for October 2023 – December 2023, there were at least 13 activities per week listed on Memory Care activity calendar. The activities included but not limited to religious events, exercise classes, scenic drives, and movie nights.

Snacks were not made available to residents in care.
It was alleged residents were not given snacks.
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: 5 of 8
Control Number 26-AS-20231207104032
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 6 of 8.
On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of residents were not given snacks. Two out of the two staff stated the staff will give snacks before lunch and after lunch to the residents and the residents have the right to refuse to eat the snacks.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of residents were not given snacks. Three out of the three staff stated the staff will give snacks before lunch and after lunch to the residents and the residents have the right to refuse to eat the snacks. S3 stated there have been a delay of residents receiving the snacks due to the kitchen staff being occupied but the residents will be given to residents before lunch or dinner service.

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.

Staff forgot to serve meals to residents in care.
It was alleged facility staff did not serve or provide meals to residents in their rooms.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of staff not serving or providing means to residents in their rooms. Two out of the two staff stated the staff are aware of which residents will eat meals in their rooms and they provide the meals and help assist residents with feeding as well.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of staff not serving or providing means to residents in their rooms. Three out of the three staff stated the staff are aware of which residents will eat meals in their rooms. All three staff stated they have not seen or heard staff not providing meals to residents in their room.

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.
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: 6 of 8
Control Number 26-AS-20231207104032
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 7 of 8.
Staff do not ensure passageways are kept free of obstructions.
It was alleged the passageways in the facility are free of obstruction.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of passageways in the facility not free of obstruction. S1 reviewed work orders placed from October 2023 – December 2023 and they were not related to issues related to passageways not free of obstruction.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of passageways in the facility not free of obstruction. Three of three staff cannot recall any incidents wherein the passageways were not free of obstruction.

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 work orders from October 2023- December 2023, 0 work orders were related to passageways were obstructed or blocked.

Staff were not present at the facility during their nighttime shift.
It was alleged there was no staff present at the facility during nocturnal (NOC) shift.

On 12/15/2023, LPA Rai interviewed two staff (S1-S2). Two out of two staff stated they did not have knowledge of an incident where nocturnal (NOC) shift care staff were not present at the facility, and no one was available to assist the residents from 10pm to 6am. S1 stated there is always coverage of staff on all three shifts, at least 1 Medication Technician and 1 care staff during the NOC shift.

On 12/16/2024, LPA Rai interviewed three staff (S3-S5). Three out of three staff stated they did not have knowledge of an incident where nocturnal (NOC) shift care staff were not present at the facility, and no one was available to assist the residents from 10pm to 6am. S4 stated there is always coverage of staff on all three shifts, at least 1 Medication Technician and 1 care staff during the NOC shift.
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: 7 of 8
Control Number 26-AS-20231207104032
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 8 of 8.
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 facility’s NOC shift caregiver “punch-in” times from October 2023 – December 2023, LPA Rai observed at least 1-2 caregivers and 1 Medication Technician on duty that were present at the facility who “punched-in” at approximately 10pm and “punched-out” at approximately 6am.

The Department has completed the investigation of the above allegations. Based on interviews conducted and record reviews, the department has found that the above allegations were UNFOUNDED, meaning that the allegations were false, could not have happened and/or are without a reasonable basis.

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)
Page: 8 of 8