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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079200623
Report Date: 05/13/2022
Date Signed: 06/07/2022 03:33:30 PM

Substantiated


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
04/11/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220411122304
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: 157DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Michela Cianciosi, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident apartment has an odor
There was no supervisor on duty
Staff did not notify authorized representative of incidents
INVESTIGATION FINDINGS:
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On 06/07/22 at 3:09PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to amend the investigation description of the allegation that there was no supervisor on duty and also to revise the citation issued. LPA explained the purpose of the visit with administrator.

Allegation: Resident apartment has an odor
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, resident’s (R1) apartment got flooded on 03/27/22 due to a clogged toilet. LPA visited R1’s room on 04/21/22 along with assisted living director (ALD) and observed a musky smell inside. ALD stated that there is an odor inside the apartment due to the presence of cat litter. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Continued on next page, LIC 9099-C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
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 5
Control Number 15-AS-20220411122304
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: 05/13/2022
NARRATIVE
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Allegation: There was no supervisor on duty
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, resident’s (R1) authorized representative (POA) stated she called the facility’s assisted living director (ALD) on 04/08/22 to request authorization to move R1 into another apartment due to the flooding that occurred inside R1’s original apartment on 03/27/22. ALD confirmed with LPA that on 04/09/22, she was not available when R1's authorized representative (POA) called and requested for assistance. Staff and maintenance did not know how to contact higher management to assist POA that day. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Allegation: Staff did not notify authorized representative of incidents
Investigation Finding: SUBSTANTIATED
Based on interviews and record reviews, resident’s (R1) authorized representative stated that R1’s apartment flooding incident occurred on 03/27/22. POA stated that facility maintenance notified them about the flooding in R1’s apartment 4 days later (03/31/22) by phone call that R1’s apartment toilet got clogged and flooded the whole unit. Executive Director confirmed with LPA that R1’s POA was not notified of the incident when it occurred on 03/27/22. The preponderance of evidence has been met. Therefore, this allegation is substantiated.

Deficiencies are cited per Title 22 California Code of Regulations and listed on LIC9099D. Failure to submit proof of corrections (POCs) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties. Exit interview conducted. Appeal Rights and a copy of this report provided via email.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20220411122304
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/13/2022
Section Cited
CCR
87303(a)((1)
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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition.
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Administrator corrected deficiency during visit. Resident’s (R1) apartment was cleaned and sanitized.
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This requirement was not met as evidenced by observed odor inside resident's apartment which posed a potential health & safety risk to residents in care
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Type B
06/27/2022
Section Cited
CCR
87411(a)
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Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on personnel job requirements and will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by no Supervisor on duty and other staff not able to contact them for a resident need, which poses a potential health & safety risk to residents in care
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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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20220411122304
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/27/2022
Section Cited
CCR
87211(a)(2)
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Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents which threaten the welfare, safety or health of residents, personnel or visitors, shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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By POC due date, Administrator agrees to submit to CCLD completed in-service staff retraining on timely communication of incidents to authorized representative in addressing resident’s individual needs and will submit to CCLD copy of completed staff retraining.
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This requirement was not met as evidenced by authorized representative not notified of incident when it occurred which posed a potential health & safety risk to residents in care
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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 FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
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
04/11/2022 and conducted by Evaluator Daisy Panlilio
COMPLAINT CONTROL NUMBER: 15-AS-20220411122304

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: 157DATE:
05/13/2022
UNANNOUNCEDTIME BEGAN:
04:30 PM
MET WITH:Michela Cianciosi, Executive DirectorTIME COMPLETED:
05:30 PM
ALLEGATION(S):
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Resident apartment is not appropriate for level of care of resident
INVESTIGATION FINDINGS:
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On 05/13/22 at 3:30PM, Licensing Program Analyst (LPA) D Panlilio conducted an unannounced subsequent visit and met with administrator to deliver the findings of above allegations. LPA explained the purpose of the visit with administrator.

Based on interviews and record reviews, resident (R1) was first admitted at the facility on 08/20/20 and was placed in an assisted living apartment (commingled living) based on the Level one health & evaluation results (reappraisals) done by the assisted living director (ALD). Re-appraisals were completed twice a year on R1. LPA reviewed R1’s reappraisal documents dated 08/27/20, 11/04/20, 06/11/21 and 09/28/21. Level of care assessments show R1 does not require assistance with activities of daily living (ADLs) and does not have a history of wandering, disruptive, aggressive, verbal or socially inappropriate behaviors. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is unsubstantiated. Exit Interview conducted and a copy of this report provided via email.

Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 622-2621
LICENSING EVALUATOR NAME: Daisy PanlilioTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 05/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 5