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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:30:29 PM


Document Has Been Signed on 09/10/2024 12:30 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
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612



FACILITY NAME:KENSINGTON AT WALNUT CREEK, THEFACILITY NUMBER:
079201241
ADMINISTRATOR:VILLANUEVA, JOSEPHFACILITY TYPE:
740
ADDRESS:1580 GEARY ROADTELEPHONE:
(925) 973-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:200CENSUS: 144DATE:
09/10/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Joseph Villanueva, Executive DirectorTIME COMPLETED:
12:35 PM
NARRATIVE
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On 09/10/2024 Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management - Deficiency. LPA met with Executive Director (ED), Joseph Villanueva, and explained the purpose of the visit.

LPAs L. Alexander and G. Luk conducted an Annual Inspection on 08/07/2024 and cited for CCR 87707(c)(5) and HSC 1569.625(b)(2). The Plan of Correction (POC) original due date was 08/30/2024. The POCs that were reviewed were incomplete. LPA L. Alexander emailed ED on 09/09/2024 to confirm status that the POCs submitted were complete. The POCs included copies of resident's medical assessments and staff annual training. ED stated that resident's responsible party will submit medical assessment. ED stated that the staff training needed to be uploaded in their system by Human Resources Team and downloading for the staff to complete for 2024. ED stated that they will have the staff complete all RCFE required training by the end of the year. Meanwhile, ED requested if they could have more time for staff to complete the required training. LPA L. Alexander recited the uncleared deficiencies and scheduled a new POC due date.

Facility has the following deficiencies that was not cleared:

CCR 87707(c)(5)


HSC 1569.625(b)(2)

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct the deficiencies may result in civil penalties.


Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
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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Document Has Been Signed on 09/10/2024 12:30 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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 AT WALNUT CREEK, THE
FACILITY NUMBER: 079201241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
87707(c)(5)

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(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:
(5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.
This requirement is not met as evidenced by:
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Executive Director (ED) has agreed to obtain current medical assessments for R5. ED will submit documentation to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above by not having current medical assessments for R5 which poses a potential health and safety risk to persons in care.
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Type B
10/11/2024
Section Cited
HSC1569.625(b)(2)

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(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
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Executive Director has agreed to obtain current annual training for S6 and S7 and will submit completed training to CCLD by POC date.
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Based on record review, the licensee did not comply with the section cited above by not having current annual training for S6 and S7 which poses a potential health and safety risk to persons 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) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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