435202775-3-10-2026-26-AS-SRAI-DS2V7T-20260310161140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 435202775
Report Date: 03/10/2026
Date Signed: 03/10/2026 04:11:58 PM

Document Has Been Signed on 03/10/2026 04:11 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
CENTRAL COAST CR/RES, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME:	WATERMARK AT ALMADEN, THE		FACILITY NUMBER:	435202775
ADMINISTRATOR/ DIRECTOR:	SHEARER, KELLIE		FACILITY TYPE:	740
ADDRESS:	4610 ALMADEN EXPRESSWAY		TELEPHONE:	(669) 258-4567
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95118
CAPACITY: 240		CENSUS: 193	DATE:	03/10/2026
TYPE OF VISIT:	Case Management - Other	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	01:15 PM
MET WITH:	Interim Executive Director (ED) Brenda Ritter		TIME VISIT/ INSPECTION COMPLETED:	04:15 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) Simi Rai conducted an unannounced Case Management visit in regards to two Death Reports received by the Department from the facility for resident R1 and R2 and deliver an immediate exclusion letter for an individual (S1) . LPA met with Interim Executive Director (ED) Brenda Ritter and stated the purpose of the visit. During today's visit, LPA Rai conducted an initial follow up on a Death Report for resident (R1). On 03/09/2026, the Department received a Death Report for resident (R1) who passed away at the facility on 03/01/2026. Based on Death Report, facility staff found resident on the floor and facility staff called 911 and paramedics arrived at the scene. During today's visit, LPA Rai obtained the following documents of R1 which include but not limited to R1's Appraisal/Needs and Services Plan, Physician's Reports and Progress Notes. At this time, this case is under review and the Department will conduct a follow up visit, if warranted. During today's visit, LPA Rai hand deliver an immediate exclusion letter for an individual (S1) who the Department determined engaged in conduct inimical as a staff in the facility. The letter was handed to the Interim Executive Director (ED) Brenda Ritter. ED stated the facilty records show S1 was not employed by the facility, therefore S1 was not present at the facility. ED stated they will ensure all staff prior to working at the facility will obtain a California clearance or a criminal record exemption. ED agreed and understood. During today's visit, LPA Rai conducted a follow up on a Death Report for resident (R2). On 6/23/2025, the Department conducted a case management visit to follow up on Incident Report/Death Report for resident (R2) who sustained an injury from an unwitnessed fall and passed away at the hospital. Continuation on LIC 809-C, Page 1 of 3.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/10/2026

NARRATIVE

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The Department received an Incident Report for an incident which occurred on 6/20/2025 wherein R2 had an unwitnessed fall in resident's room in the Memory Care unit. R2 stated the right side of the body and head was "hurting". The facility staff called the paramedics and R2 was taken to the hospital. The Department received a Death Report wherein R2 passed away at the hospital on 6/20/2025 and the immediate cause of death is unknown.

On 12/19/2025, the Department interviewed two staff (S2-S3). Two out of two staff stated the residents are checked on by staff every hour for safety, but they do not document their safety checks. S2 stated the residents in the memory care units do not have call buttons or alarm pendants and the residents will verbally call for staff if they require assistance. Two out of two staff stated resident R2 was a fall risk resident.

On 12/24/2025, the Department interviewed four residents (R3-R6). Four out of four residents stated they feel safe at the facility and do not have any complaints.

On 12/24/2025, the Department interviewed three staff (S4-S6). Three out of three staff stated the residents are checked on by staff every hour for safety, but they do not document their safety checks. Three out of three staff stated the resident R2 was a fall risk resident. S4 stated he/she checked on R2 the day of the incident on 6/20/2025 wherein R2 was calling for help in the room and S4 found R2 on the floor. S4 stated R2 was trying to put on clothes when R2 fell on the floor. S4 stated R2 was assessed R2 and called 911 and the paramedics transported R2 to the hospital. S4 stated R2 was checked an hour before the fall incident on 6/20/2025 and R2 was in bed sleeping. S5 stated R2 and R2’s family was recommended for a private companion but R2’s family refused.

On 1/7/2025, the Department interviewed 1 staff (S6). S6 stated he/she assessed resident R2 on 6/20/2025 and found R2 on the floor of the room. S6 stated R2 complaining of pain on the right side of rib area. S6 called 911 as a response to R2’s fall. S6 stated resident R2 was a fall risk resident.

On 2/2/2026, the Department interviewed physician (P1) from Santa Clara County’s office. P1 stated the rib fracture complicated R2’s underlying chronic diseases and contributed to R2’s death. P1 stated the trauma from the injury placed too much stress on R2’s body.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 03/10/2026

NARRATIVE

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On 2/3/2026, the Department interviewed 1 staff (S5) to further clarify information provided on 12/24/2025. S5 stated residents are determined to be fall risk using the facility’s fall risk assessment tool. S5 stated the facility staff provided assistance with resident R2’s activities of daily living (ADLs), checked on resident R2 frequently and reassessed every time R2 has a fall. S5 stated the facility staff was concerned about R2’s fall incidents where S5 spoke to R2’s family and recommended a private caregiver but R2’s family refused due to the cost.

Based on review of R2’s assessments after 11 documented falls from 5/24/2025 to 6/20/2025, the assessments would evaluate R2’s condition at the time of each incident but it did not result in documented revisions, modifications, or escalation of the care plan. According to R2’s gait analysis, R2 had a loss of balance while standing, and had decrease in muscle coordination. R2 used an assisted device and required assistance when moving from place to place. R2 was noted to be between a moderate to high fall risk.

Based on review of R2’s Service Plan Report dated 4/9/2025, the report included fall prevention measures. The facility staff documented on R2’s progress notes from 5/24/2025 to 6/20/2025, R2 had 11 witnessed and unwitnessed falls in the facility. R2’s Service Plan dated 4/9/2025 remained on file and the facility staff did not update R2’s fall prevention plan after having 11 documented falls.

Based on review of R2’s Death Certificate, R2’s immediate cause of death was due to a rib fracture complicating neurodegenerative disease.

Deficiencies were cited from California Code of Regulations, Title 22 during today’s visit, see LIC 9099-D.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

This report was reviewed with Interim Executive Director (ED) Brenda Ritter and a copy of the report was provided. Appeal Rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Romeo Manzano
NAME OF LICENSING PROGRAM ANALYST: Simranjit Rai
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/10/2026 04:11 PM - It Cannot Be Edited

Created By: Simranjit Rai On 03/10/2026 at 03:28 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 2580 N. FIRST STREET, STE. 350
SAN JOSE, CA 95131

FACILITY NAME: WATERMARK AT ALMADEN, THE	FACILITY NUMBER: 435202775
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/10/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/11/2026 Section Cited CCR 87463(a)	1 2 3 4 5 6 7	87463(a)The pre-admission appraisal,..., shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition,... This requirement is not met as evidenced by:	1 2 3 4 5 6 7	Administrator stated to submit a written plan of action understanding regulation and will ensure appraisals are updated in writing which include signigficant changes in condition by POC due date. Administrator agreed and understood.
	8 9 10 11 12 13 14	Based on record review and interviews, R2’s appraisal dated 4/9/2025 which included the fall prevention was not updated after facility staff noted significant changes of R2 having documented 11 falls from 5/24/2025 to 6/20/2025 which poses/posed an immediate health, safety or personal rights risk to	8 9 10 11 12 13 14	(con't) persons in care.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Romeo Manzano
NAME OF LICENSING PROGRAM MANAGER:

	Simranjit Rai
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2026

LIC809 (FAS) - (06/04)

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