079200623-3-2-2022-15-AS-KHOS-CE5KCE-20220505074701

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079200623
Report Date: 03/02/2022
Date Signed: 03/02/2022 02:04:29 PM

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
06/19/2020 and conducted by Evaluator Lizette Francisco

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20200619084441

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: 154	DATE:	03/02/2022
		UNANNOUNCED	TIME BEGAN:	12:40 PM
MET WITH:	Michela Cianciosi, Executive Director		TIME COMPLETED:	02:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

-Facility staff did not obtain resident's prescribed medical devices
-Facility staff did not ensure the residents blood sugar was monitored
-Facility staff did not provide resident records upon request
-Facility staff did not provide resident with their medications upon relocation
-Lack of supervision resulting in residents engaging in altercations
-Facility staff spoke inappropriately to resident
-Facility staff charged resident for services not needed
-Facility is not kept clean

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 3/2/2022 at 12:40 PM, Licensing Program Analyst (LPA) L. Francisco arrived unannounced to deliver findings for the above allegations. LPA met with Executive Director, Michela Cianciosi and explained the purpose of the visit.

During the course of the investigation, LPA obtained information, collected documents, interviewed residents and staff.

Allegation: Staff did not obtain resident’s prescribed medical devices.

However, based on record review, LPA observed a doctor’s order for R1’s insulin on 6/29/2016. Due to a change in insulin orders, R1 was issued a new doctor’s order on 11/1/2017.

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: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

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

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 15-AS-20200619084441

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: 03/02/2022

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
26
27
28
29
30
31
32

There was no order for a specific size needle. S3 stated all sizes are standard for all residents.

Allegation: Facility staff did not ensure residents blood sugar was being monitored.

However, LPA reviewed R1’s Treatment Administration Record (TAR) and observed staff documenting R1’s blood sugar level.

Allegation: Facility staff did not provide residents records upon request

Based on record review of facility's policy for record request, a written request is required. S1 stated there was no written request on file requesting records for R1.

Allegation: Facility staff did not provide resident with their medications upon relocation

LPA reviewed R1’s Medication Release Form and observed it was entrusted to and signed by R1’s DPOA.

Allegation: Lack of supervision resulting in residents engaging in altercation

Based on interview with 8 residents and 4 staff, 8 of 8 residents and 4 of 4 staff stated they have not observed an altercation between two residents.

Allegation: Staff spoke inappropriately to resident

LPA interviewed 8 residents and 5 staff. 8 of 8 residents stated staff does not speak inappropriately to them or have not observed of staff speaking inappropriately to other residents. 5 of 5 staff stated they do not speak inappropriately to residents.

REPORT CONTINUES ON 9099C

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 15-AS-20200619084441

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: 03/02/2022

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
26
27
28
29
30
31
32

Allegation: Facility staff charged resident for services not needed

Although room service and pick up service are subject to additional charge. No forthcoming information was provided, therefore, LPA was unable to determine if resident requested room and pick up service.

Allegation: Facility is not kept clean

Based on information obtained, R1’s room was “filthy”. During record review of R1’s Admission Agreement, residents are provided weekly housekeeping. LPA was unable to obtain additional information, however, LPA interviewed 8 residents and 8 of 8 residents stated they are satisfied with housekeeping.

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: Lizette Francisco	TELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:	DATE: 03/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3