Watermark at San Ramon, the

On the allegations that staff were not showering residents, Staff are not ensuring the residents are properly dressed and groomed, Staff allow the residents to sleep on wet and dirty sheets, Staff did not properly report an incident involving a resident , and Staff are not meeting the residents diabetic needs the following was found: Interviews and document reviews confirmed that residents were not consistently receiving showers. End-of-shift reports documented that showers had been completed, but this conflicted with observations recorded in disciplinary documentation. Memory Care Director stated that they had received complaints from staff regarding inconsistent hygiene practices and personally observed residents who had not been bathed. Memory Care Director also reported that S2 “would lie and say she tried to shower residents but wouldn’t follow through.” Disciplinary documentation issued to S2 on 01/23/25 confirmed that Resident was observed with a soiled bed, a soiled brief on the floor, and a soiled comforter nearby. S2 received a final written warning as a result. Similarly, S3 received a final written warning dated 01/24/25 after Resident was found following an unwitnessed fall with blood in the shower, urine on the sheets and bed protector, and a dirty brief under the sink. The room had not been cleaned. These incidents were formally documented and observed by facility management. Residents were also not consistently groomed or dressed. Memory Care Director reported having observed multiple residents still in pajamas late into the day and confirmed that some staff were not assisting residents with dressing. It was also reported that there were residents that were have found put in bed with their daytime clothing and not dressed out for bed at night. Documentation further supported that residents were allowed to sleep on wet and dirty bedding. The disciplinary notice for S2 referenced a resident found in a soiled bed with visibly unclean linens. The notice for S3 detailed the condition of a resident room where urine and blood were present, and incontinence items had not been disposed of. These were documented observations that resulted in disciplinary action. Memory Care Director also confirmed knowledge of incidents where residents bedding was left soiled by staff. Report Continues on LIC9099-C 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 26 27 28 29 30 31 32 Report Continued from LIC9099-C Although the facility conducted in-service training on reporting expectations on 12/12/24 and 03/26/25, record reviews and interviews showed that staff were not consistently reporting incidents as required. Memory Care Director stated, “Staff have scratched off concerns on end-of-shift reports instead of reporting incidents.” Corrective action followed these reporting failures. Because staff where failing to follow the proper reporting requirements CCL did not receive reports as required. The investigation also confirmed that staff did not consistently meet the diabetic needs of residents. Memory Care Director reported that staff were observed giving sugary beverages to residents with diabetic diagnoses and had to be directed to stop. Care plans for diabetic residents contained specific dietary instructions that were not being followed. No documentation was available showing oversight or review of adherence to these care plans. Review of text messages also confirmed concerns from staff that other staff members were not effictively providing care to residents as required. Based on LPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. 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 26 27 28 29 30 31 32 On the allegations that staff were not feeding residents, staff are not ensuring the residents are consuming an appropriate amount of fluids, Staff are allowing the residents to eat food with ants, and Staff do not prevent a resident from attacking other residents, the following was found: There was no documentation to support that residents were denied meals. Staff and supervisory interviews confirmed that feeding support is provided only with physician orders. Interviews with residents produced that all residents were satisfied with their food service. The kitchen was also observed fully stocked. Memory Care Director confirmed that staff had previously fed residents on the first floor, but that practice ended unless feeding orders were in place. On the allegation that staff were not ensuring adequate hydration in-service training focused on hydration was conducted on 12/12/24. Memory Care Director stated that “after the in-service, hydration improved,” however prior to in service training there was not documented incidents were residents were not consuming enough fluids. The facility did experience an ant infestation in the summer of 2024, but extermination services were called, and the issue was addressed. LPA previously had obtained extermination records and observed the facility to be free of ants. There was no evidence presented that residents consumed food with ants. While ants were documented in some resident rooms, neither interviews nor facility records confirmed that food contamination occurred. The allegation that staff failed to prevent resident-to-resident aggression could not be substantiated. LPA reviewed incident logs, internal reports, and conducted interviews with staff and residents. No documentation or statements supported that any physical aggression between residents occurred during the investigation window. Staff where able to identify de-escalation techniques when asked. Based on the information obtained, the above allegations are unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED

On 12/30/2024 at 3:00PM, Licensing Program Analyst (LPA) A. Gomez arrived unannounced to conduct a case management review related to complaint 15-AS-20240514173549. Upon arrival, LPA met with Kiel Stromgren, Executive Director, and explained the purpose of the visit. The facility is licensed for 95 non-ambulatory of which 15 may be bedridden. During the course of the investigation, The Department conducted interviews, and reviewed files. It was discovered that staff were not adequately trained to meet the facility’s operational needs, as required by state licensing standards. Several staff members were found to be unfamiliar with key procedures and protocols that are critical for maintaining quality care and ensuring the safety of residents. In addition to the lack of training, the d epartment found that the facility was not properly maintaining resident or staff records, which is a violation of regulatory requirements. Upon review, it was determined that several records that should have been readily available, including incident reports and other key documentation, were missing or incomplete. The facility was unable to provide the requested incident reports to the Department and the Department did not have record of the incident reports being submitted by the facility. Report Continues on LIC809-C 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 26 27 28 29 30 31 32 THE FOLLOWING DEFICIENCIES WERE OBSERVED DURING INVESTIGATION: · Staff are not adequately trained to provide care · Facility is not maintaining required documents · Facility is not following proper reporting procedures The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

This is an amendment to an original LIC9099-C report issued on 12/30/2024 On the allegation that the resident suffered a fall resulting in hospitalization, the Department found during interviews, record reviews, and observations that R1 experienced multiple documented falls, including significant incidents on 1/26/2023 and 2/29/2024. These falls led to hospitalizations, with the fall on 2/29/2024 resulting in an intracerebral hemorrhage. R1’s care plan, updated after the 1/26/2023 fall, required the use of a walker and physical therapy to prevent further falls. However, staff interviews revealed that even after the physician’s report was updated requiring the use of walker, R1 frequently ambulated without his walker and often wore inappropriate footwear, such as flip-flops, which increased his fall risk. Staff members, including S1 and S2 confirmed that although they encouraged R1 to use the walker, they did not enforce this consistently nor did they implement any fall preventatives to ensure R1’s safety. R1 had a habit of walking to the kitchen during midnight Environmental observations also revealed that high-risk areas, such as the kitchen, were accessible to R1 without adequate supervision or physical barriers to restrict movement. Additionally, staff training records indicated that while fall prevention training was available, it was not effectively applied in practice, leading to lapses in supervision. Therefore, the allegation that the resident suffered a fall resulting in hospitalization is substantiated. On the allegation that staff did not safeguard the resident’s personal items, the Department found during interviews, record review, and observations that there were inconsistencies in the documentation and securing of R1’s belongings. The investigation included a review of R1’s personal belongings inventory, which revealed gaps in the documentation of items. Interviews with staff, including S1 and S4, indicated that staff shortages and high turnover contributed to lapses in securing residents’ personal items. S4 admitted that personal items were sometimes left unsecured, particularly during busy shifts, which increased the potential for loss or misplacement. R1’s family also reported missing items and noted that these belongings had not been accounted for during their last visit. Report Continues on LIC9099-C 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 26 27 28 29 30 31 32 This is an amendment to an original LIC9099-C report issued on 12/30/2024 Continued from LIC9099-C The facility lacked protocols for safeguarding resident belongings, and staff confirmed that procedures to secure items were not consistently followed. Therefore, the allegation that staff did not safeguard the resident’s personal items is substantiated. On the allegation that staff did not follow physician’s instructions, the Department found during interviews, record review, and observations that R1’s care plan, updated following his fall on 1/26/2023, mandated the use of a walker and continuous supervision due to their high fall risk. Interviews with multiple staff members, including S2 and S3, indicated that although staff were aware of the requirement, R1 frequently moved around the facility without their walker and unassisted. Facility incident reports documented instances where R1 was observed walking without the walker and without staff supervision, as required by R1’s care plan. Despite these incidents, no documented corrective actions were taken to ensure compliance with the physician’s instructions. Additionally, statements from R1’s family expressed concerns over the lack of adherence to the care plan, noting that R1 was often seen ambulating unassisted. The evidence shows that the facility did not consistently follow the physician’s instructions to mitigate R1’s risk of falling. Therefore, the allegation that staff did not follow physician’s instructions is substantiated. ****An immediate civil penalty of $500 is being assessed on todays date**** The following deficiencies were observed (see LIC 9099D) and cited from the California Code of Regulations, Title 22. Substantiated findings will be reviewed for possible enhanced civil penalty assessment. Exit interview conducted with Executive Director. A copy of this report and appeal rights was provided.

On 12/5/2023 starting at 8:45 AM, Associate Governmental Program Analyst (AGPA) L. Francisco arrived unannounced to conduct a Case Management visit as a result of complaint. (CN# 15-AS-20220817112257). AGPA met with Memory Care Director, Laquisha Wong and explained the purpose of the visit. AGPA later met with Executive Director, Kiel Stromgren. During a visit on September 20, 2022, the Department attempted to review three residents records. However, the records maintained for 3 of 3 staff (S1, S2 and S3) were incomplete. 3 of 3 staff did not have application and contact information on file. In addition, there were no record of termination date and reason for termination for S2. The Department discussed the issue with former Resident Care Director, Sangeeta Devi and an email was sent regarding staff files. The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided.

The Department investigated the allegations that the resident sustained a fracture while in care. The Department concluded staff failed to acknowledge R1’s bruising surrounding his left shoulder prior to an office visit at Kaiser Permanente (KP) on January 13, 2022. The Department obtained a copy of R1’s discharge notes from KP where R1 was diagnosed with distal clavicle displaced fracture and soft tissue swelling. Photos obtained shows purple and yellow bruises that extended from the back below the neck, and to the left shoulder blades behind the left armpit. Bruising was also present in the front left shoulder. Based on interviews with 6 staff, 1 of 6 staff was the only one to have any knowledge of R1 sustaining an injury while at the facility. Staff (S6) observed R1’s shoulder being bruised, and other staff was not aware of what happened. R1’s physician’s report indicates resident needs assistance with bathing and toileting. AGPA investigated the allegation that the facility failed to meet reporting requirements. Based on record review of R1’s discharge notes from January 13, 2022, R1 was admitted to KP for neck pain and bruising on left shoulder from fall that occurred on January 9, 2022. There are no records of the Department receiving an incident report of R1’s fall. AGPA investigated Resident’s care plan is inaccurate. Based on a record review of R1’s care plan dated May 17, 2022, AGPA observed boxes under “assistive devices” were checked on the care plan form. However, during the interview with staff indicated R1 does not need an assistive device and can walk independently. The box on the form was checked off incorrectly. Based on The Department observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED. California Code of Regulations (Title 22, Division 6, Chapter 8) are cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director. 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 26 27 28 29 30 31 32 Allegation: Personal Rights – Resident sustained multiple injuries while in care. Based on record review of R1’s incident report, R1 smashed R1’s left pinky on 2/21/22, and sustained a skin tear on right elbow on 7/16/22. However, both incidents were unwitnessed, and according to R1’s assessment, R1 does not need 1 on 1 care. On 2/21/22, R1 was admitted to the hospital and was treated with stitches for R1’s left pinky. Allegation: Staff are not following a licensed physician’s orders for a resident Based on information obtained by complainant, R1 is being administered psychiatric medication and has an assisted device without a doctor’s order. AGPA reviewed R1’s Medication Administration Record, and did not observe psychiatric medication listed on the MAR. In addition, AGPA reviewed R1’s doctor’s order, and did not observe an assistive device. According to an interview with staff by the Department, R1 does not use an assistive device and can walk independently. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violatiosn did or did not occur, therefore the allegation are UNSUBSTANTIATED. Exit interview conducted and a copy of this report provided to Executive Director.

On 12/1/23, AGPA obtained a printed Electronic Medication Administration Record (MAR) for R1 from November of 2022 to January of 2023. AGPA observed the following dates were not initialed by staff: 11/16/22, 12/15/22 and 12/27/22. S6 stated that if the MAR is blank, there may have been an internet issue and so staff will hand initial it on a Medication Administration Record. However, facility was not able to produce to AGPA a copy of the Medication Administration Record. Based on AGPAs observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED . California Code of Regulations (Title 22, Division 6, Chapter 8), are being cited on the attached LIC 9099D. Exit interview conducted. Appeal Rights and a copy of this report is provided to Executive Director. 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 26 27 28 29 30 31 32 There is a sticky note placed on the washer machine and dryer with resident's name. In addition, S1 writes the name of the resident on the white board of which resident's clothes are currently in the washer and dryer machine. AGPA reviewed R1's Personal Property and Valuables, and did not observe any personal items listed for facility to safeguard. It was alleged staff did not meet residents ADL needs. However, based on interview with 5 staff, residents are checked every 2 to 3 hours. On 11/8/23, AGPA interviewed 2 residents and 2 of 2 residents stated staff checks on them regularly, and if they need assistance, then they will use the call button. On 12/1/23, AGPA attempted to interview R1 and R2 but unable to obtain additional information. It was alleged due to insufficient staffing, resident's room is not cleaned. On 11/8/23, AGPA interviewed 2 residents and 2 of 2 residents stated they have no issues with housekeeping. AGPA interviewed 4 staff and 4 of 4 staff stated housekeeping is completed once a week or as needed. On 12/1/23, AGPA attempted to interview R1 and R2, but unable to obtain additional information. It was alleged due to insufficient staffing, resident's linens are not changed timely. On 11/8/23, AGPA interviewed 4 staff and 4 staff stated linens are changed once a week, or as needed if it's soiled or dirty. Interview with 2 residents revealed that staff changes their linens. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegations are UNSUBSTANTIATED . Exit interview conducted and a copy of this report provided to Executive Director.

On 2/23/2023 at 2:15 PM, Licensing Program Analyst (LPA) L. Francisco conducted a Case Management while at the facility for complaint #15-AS-20230216161224. LPA met with Executive Director, Kiel Stromgren and Resient Care Director, Sangeeta Devi and LPA explained the purpose of the visit. At 2:15 PM, LPA observed CCLD complaint information is posted by the reception desk. However, not in the correct size of 20"x26" The following deficiency was observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health. Failure to correct deficiency by POC date may result in additional Civil Penalties. Exit interview conducted. Appeal Rights and a copy of this report provided to Executive Director.