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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079200623
Report Date: 05/20/2022
Date Signed: 05/20/2022 03:41:17 PM


Document Has Been Signed on 05/20/2022 03:41 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:KENSINGTON, THEFACILITY NUMBER:
079200623
ADMINISTRATOR:MICHELA CIANCIOSIFACILITY TYPE:
740
ADDRESS:1580 GEARY RDTELEPHONE:
(925) 943-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:200CENSUS: 152DATE:
05/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:Katelyn Wilson, Director of Assistant LivingTIME COMPLETED:
03:50 PM
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On 5/20/2022 at 2:30 PM, Licensing Program Analyst (LPA) C. Fowler arrived unannounced to conduct Infection Control Inspection. LPA met with Director of Assistant Living, Katelyn Wilson and explained the purpose of the visit. Executive Director, Michela Cianciosi arrived at approximately 3:00pm. The facility’s fire clearance was approved for 200 residents.

LPA toured the facility with Katelyn Wilson and Michela Cianciosi including but not limited to 4 residents apartments, bathrooms, activity rooms, kitchen, common area and courtyard. LPA observe lighting in all rooms are adequate for the comfort and safety of the residents. LPA observed lighting in all rooms are adequate for the comfort and safety of the residents. Residents’ bathrooms are equipped with grab bars and non-skid tape. There is a minimum of one week supply of nonperishable and 2-day of perishable foods. Centrally stored medications, sharps and toxic are locked and inaccessible to residents in care.

No deficiencies cited during visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) -62-2621
LICENSING EVALUATOR NAME: Carol FowlerTELEPHONE: (510) 622-2715
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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