079200623-11-5-2021-15-AS-KHOS-C9CPLX-20211203102528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200623
Report Date: 11/05/2021
Date Signed: 11/05/2021 03:59:53 PM

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
11/25/2020 and conducted by Evaluator Leslie Ibo

COMPLAINT CONTROL NUMBER: 15-AS-20201125134440

FACILITY NAME:	KENSINGTON, THE		FACILITY NUMBER:	079200623
ADMINISTRATOR:	MICHELA CIANCIOSI		FACILITY TYPE:	740
ADDRESS:	1580 GEARY RD		TELEPHONE:	(925) 943-1121
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	200	CENSUS:	DATE:	11/05/2021
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Michela Cianciosi & Katelyn Wilson		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Staff failed to protect a resident from harm while in care
Staff failed to address a resident's change in medical condition while in care

INVESTIGATION FINDINGS:

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On 11/5/2021 Licensing Program Analyst (LPA) L. Ibo visited the facility to deliver findings on the above allegation. This complaint is from November 2020 and primary investigation was completed by another LPA Praveen Singh , complaint was re-assigned to LPA L. Ibo. LPA met with Administrator Michela Cianciosi and explained the reason for the visit.

During the complaint investigation LPA conducted document review and interview, based on the SOC341 sent to CCL office on 11/9/2020 , R2 pushed and punched R1’s forehead causing R1 to fall on the floor, the staff assessed residents involved (R1 & R2) , separated both residents and called 911 were both residents taken to the hospital.

...Continue to LIC9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20201125134440

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: KENSINGTON, THE	FACILITY NUMBER: 079200623
	VISIT DATE: 11/05/2021

NARRATIVE

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During the course of investigation, based on interview and records review. Staff monitored R1's change of condition from not eating well on 10/1/2020 - 10/14/2020, alert charting was triggered on 10/6/2020. Per S2, there was skin redness noticed by one of the staff, the doctor was informed and staff requested for medication but the resident left the facility before receiving any response from the doctor.

Based on information gathered during the investigation, there was not a substantial amount of evidence to support the allegations and no independent evidence or witnesses could be obtained to support that staff failed to protect a resident from harm while in care & staff failed to address a resident's change in medical condition while in care . 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.

Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Leslie Ibo	TELEPHONE: 510-286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC9099 (FAS) - (06/04)

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