079200623-8-7-2024-15-AS-KHOS-D8CJW5-20240821072409

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200623
Report Date: 08/07/2024
Date Signed: 08/07/2024 07:35:30 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
06/06/2023 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20230606093919

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:	0	CENSUS: 143	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Joseph Villanueva, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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1. Facility is not administering medication as prescribed.
2. Facility did not administer insulin injections in a timely manner.

INVESTIGATION FINDINGS:

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On 08/07/2024 at 10:30 AM, Licensing Program Analysts (LPAs) L. Alexander and G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegations above. LPAs met with Executive Director, Joseph Villanueva.

During the course of investigation, LPA L. Alexander interviewed complainant, resident and staff. LPAs obtained and reviewed documents including physician's report, medication administration records (MAR), centrally stored medication list, physician's medication orders, med tech staff schedules.

LIC9099-C Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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-20230606093919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KENSINGTON, THE	FACILITY NUMBER: 079200623
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2024 Section Cited CCR 87465(c)(2)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. (c) If the resident's physician has stated in writing...(2)... medication is given according to the physician's directions. This requirement is not met as evidence by:	1 2 3 4 5 6 7	Administrator agreed to submit a inservice training with med techs and nurses and will conduct ongoing training every month. Signed training will be submitted to CCLD by POC date.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.	8 9 10 11 12 13 14
Type B 08/26/2024 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...with those activities of daily living such ...assistance with taking prescribed medications. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director has agreed to training for administering medication and submit staff sign in sheet to CCLD by POC date.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.	8 9 10 11 12 13 14

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

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

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Control Number 15-AS-20230606093919

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KENSINGTON, THE	FACILITY NUMBER: 079200623
	VISIT DATE: 08/07/2024

NARRATIVE

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Allegation: Facility is not administering medication as prescribed.
Substantiated.

On 06/12/2023 LPA spoke with RP who stated that the Med Techs did not have the insulin medication to give R1 on one morning. RP stated that R1 should be receiving insulin injections morning and evening. LPA reviewed doctor's orders from 05/08/2023 thru 11/28/2023 that indicates Insulin Lispro should be scheduled administered two (2) times a day at 9am and 5pm, but not including before meals. LPA interviewed W1 that stated on 05/30/23 R1 did not receive their insulin injection medication until after 11:30pm. W1 further stated that R1 did not receive their morning injection until after 10:30am. W1 stated that the facility was contracting nurses from outside agencies to come for medication administration. W1 further stated that R1's medication was "fast acting," and that breakfast was not served on time. The MAR indicated there was a lapse in insulin given on 06/05/23 with no written documentation on why insulin was stopped.

Allegation: Facility did not administer insulin injections in a timely manner.
Substantiated.

On 12/08/2023 LPA interviewed R1 that stated that the insulin prescribed was "70/20 or 70/25". R1 stated their doctor's prescribed that she takes her medications 15-30 mins before she eats. R1 stated that they are on a "sliding scale" in which they have to test their glucose and depending what the level is (i.e.,100-150) that is how much units of insulin is determined that they need for their dosage. Record review indicated that R1's current medication list for insulin Lispro was prescribed to inject 2 units under the skin two (2) times and three (3) times a day before meals indicated by physician's orders written on 05/18/2023 and 06/05/2023 respectively.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegations is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D. Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

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