079200623-9-24-2021-15-AS-KHOS-CKLPAW-20221027110924

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200623
Report Date: 09/24/2021
Date Signed: 09/24/2021 11:34:47 AM

Unsubstantiated

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
09/16/2021 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20210916120610

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: 144	DATE:	09/24/2021
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Michela Cianciosi, Executive Director		TIME COMPLETED:	11:45 AM

ALLEGATION(S):

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Facility heating and air conditioner is in disrepair
Facility has pests

INVESTIGATION FINDINGS:

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On 9/24/2021 starting at 9:20am, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to conduct complaint investigation for the above allegations. LPA met with Executive Director, Michela Cianciosi and explained the purpose of the visit.

During the complaint investigation, LPA toured memory care and interviewed staff. Based on information obtained, it was alleged heating and air conditioner is in disrepair. Memory care's heating and air is centralized and LPA observed thermostat was set to 72 degrees F. Interview with S1 revealed that air conditioning on one side of memory care is in disrepair. However, LPA observed a portable air conditioning in a resident's room. Review of records indicates that on 8/31/2021, facility submitted an incident report of the issue to CCL and has been working with heating and air company called Ontario Refrigeration.

REPORT CONTINUES ON 9099C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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-20210916120610

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: 09/24/2021

NARRATIVE

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Based on information obtained by reporting party, facility has pests. During the tour on 9/24/2021 of memory, LPA did not observed vermin. S1 stated there were complaints of cockroaches and ants, but Western Exterminator Company conducted an inspection of entire building and completed treatment. LPA confirmed an invoice was issued on 5/10/2021 to facility.

Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC9099 (FAS) - (06/04)

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