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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 06/14/2023
Date Signed: 06/14/2023 12:24:32 PM


Document Has Been Signed on 06/14/2023 12:24 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, 744 P STREET, MS 9-14-8201
SACRAMENTO, CA 95814



FACILITY NAME:KENSINGTON AT WALNUT CREEK, THEFACILITY NUMBER:
079201241
ADMINISTRATOR:BRADLEY, DEBORAHFACILITY TYPE:
740
ADDRESS:1580 GEARY ROADTELEPHONE:
(925) 973-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:200CENSUS: 143DATE:
06/14/2023
TYPE OF VISIT:OfficeANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Deborah Bradley, Administrator
Andrew Kohlberg, Applicant		TIME COMPLETED:
11:20 AM
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Component II completion: Successful

Facility Type: Residential Care Facility for Elderly (RCFE)
Application Type: Change in Ownership (CHOW)
Capacity: 200
Census (if any clients in care): 143
COMP II Participants: Deborah Bradley, Administrator
Andrew Kohlberg, Applicant
Interview Method: Telephone interview

On June 14, 2023 at 10:00 AM, Applicant and Administrator participated in COMP II. Identification of the Applicant and Administrator was verified through interview questions based on photo ID and other identifying personal information. During COMP II, Applicant and Administrator confirmed that they have read and understand community care facility licensing laws included in the Health and Safety Codes and the California Code of Regulations Title 22.

During COMP II, CAB Analyst confirmed Applicant and Administrator’s understanding of following areas:
1. Facility Operation: License type, client/resident populations, and program
2. Admission Policies
3. Staffing Requirements & Training
4. Restrictive/Prohibited Health Conditions
5. General Provisions
6. Emergency Preparedness
7. Complaints & Reporting
8. Pre-licensing Readiness

Exit interview conducted with Administrator. Copy of report sent via email and request to return sign copy by end of business day today.
SUPERVISOR'S NAME: Darla NeeleyTELEPHONE: (916) 651-7817
LICENSING EVALUATOR NAME: Celia PhomphachanhTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2023
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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