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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 079201241
Report Date: 12/09/2025
Date Signed: 12/09/2025 04:46:03 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 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
10/29/2024 and conducted by Evaluator Lori Alexander-Washington
PUBLIC
COMPLAINT CONTROL NUMBER: 15-AS-20241029121159
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: 150DATE:
12/09/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Dolly Bindar, Executive Director TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Staff mismanaged residents’ medications.
Staff falsified medication administration records.
Licensee does not ensure staff administering medication to residents are appropriately trained.
INVESTIGATION FINDINGS:
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On 12/09/2025 at 10:00 AM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen conducted a subsequent visit and met with Executive Director (ED) Dolly Bindar to deliver the findings of above allegations. LPAs explained the purpose of the visit with ED.

During investigation, the LPA obtained the following documents from the facility: Resident (R) and Staff (S) rosters, medication administrator records (QMARs electronic software system), Medication Technician (Med Tech) trainings, Resident's Face Sheets, Physician's Reports, Physician's Orders, MARs (Sept/Oct/Nov 2024), Progress Notes, Medication Tech Relias Transcripts (2024), narcotic records, care plans, assessments and communication faxes. LPA interviewed staff, residents and witnesses (W).

LIC9099-C Continued...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
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-20241029121159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/09/2025
NARRATIVE
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LIC9099- C (Page 2)

Allegation: Staff mismanaged residents’ medications.
Finding: Substantiated

On 11/09/2024, Licensing Program Analyst (LPA) L. Alexander conducted interviews and reviewed facility records. During the interview, Witness (W1) stated that Resident 1 (R1) has cancer and is prescribed morphine 15mg. W1 reported that staff document the medication as administered multiple times when it was never actually given. W1 stated that R1 is often in significant pain due to missed doses. W1 further alleged that staff select “Exception” within the QMAR system and note “on hand” even when the medication is unavailable.

LPA reviewed R1’s physician’s orders, which indicated that morphine 15mg is to be administered one tablet by mouth three times daily (9:00 a.m., 12:00 p.m., and 6:00 p.m.). Review of R1’s October 2024 Medication Administration Record (MAR) revealed missing doses on 10/14/24, 10/15/24, 10/16/24, and 10/18/24. Staff 2’s (S2) chart note on 10/16/24 stated, “waiting on pharmacy to deliver not on hand.” The MAR reflects that on 10/14/24, morphine was administered at 6:00 a.m. and 2:00 p.m., and on 10/15/24, at 6:00 a.m. and 10:00 p.m., with the 2:00 p.m. dose omitted.

Allegation: Staff falsified medication administration records.
Finding: Substantiated

LPA reviewed Resident 2’s (R2) physician’s orders, which included a narcotic to be administered one pill by mouth every eight (8) hours.

LIC9099-C Continued...
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 15-AS-20241029121159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/09/2025
NARRATIVE
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LIC9099- C (Page 3)

The Medication Administration Record (MAR) dated 10/18/2024 shows that Staff 1 (S1) documented administering the narcotic at 6:00 a.m., and Staff 2 (S2) documented administration at 2:00 p.m. However, the Individual Resident Narcotic Record indicates that S1 administered the medication at 6:00 a.m., and S2 signed for administration of the same medication at 7:00 a.m.

Allegation: Licensee does not ensure staff administering medication to residents are appropriately trained.
Finding: Substantiated

W1 stated that Med Techs are still administering insulin injection medications to residents.

LPA reviewed R2’s physician’s reports, physician’s orders, care plan, MAR (Sept-Nov 24; Aug-Oct ’25) and it shows that R2 cannot administer their own injections. The MARs reveal that Med Techs were administering injections and checking blood glucose via finger stick.

On 10/16/2025 LPAs L. Alexander and K. Nguyen interviewed R2 and S1. R2 stated that they are not on insulin and that the Med Techs do not inject them. R2 has a diagnosis of dementia and physician’s orders clearly states insulin injections and blood glucose checks. S1 stated that Med Techs are not doing the insulin injections, but they are setting the PEN up for R2 and that R2 is injecting themselves. LPA asked S1 if they are using the “hand or hand” method and S1 confirmed yes.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 15-AS-20241029121159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/09/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/09/2026
Section Cited
CCR
87465(a)(6)
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CCR 87465(a)(6) – Incidental Medical and Dental Care
When requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.

This requirement was not met as evidenced by:
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Administrator agreed to review and audit all narcotic medication logs and MARs for accuracy. Administrator agreed to conduct medication documentation training for all Medication Technicians and submit proof of completion to CCL by due date.
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Based on record review and interviews, the licensee failed to ensure accurate medication administration documentation for R2. On 10/18/2024, the MAR reflected narcotic administration times of 6:00 a.m. and 2:00 p.m., while the Individual Resident Narcotic Record showed administration at 6:00 a.m. and 7:00 a.m. The discrepancy between the two documents demonstrates falsified or inaccurate medication administration documentation which poses a potential health and safety risk to the persons in care.
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Type B
01/09/2026
Section Cited
CCR
87629(b)(1)
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CCR 87629(b)(1) Injections
Injections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.

This requirement is not met as evidence by:
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Administrator will conduct an audit on all residents that receiving dr's order for injections to determine if they can self inject or require assistance with skilled professional. Will send a confirmation that audit was completed by POC due date.
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Based on record review and staff interviews, the licensee did not comply with the section cited above by ensuring that injections are administered by an appropriately skilled professional. Records show that Medication Technicians (Med Techs), who are not appropriately skilled professionals, were administering insulin injections and performing blood glucose checks for R2. S1 confirmed that Med Techs “set up” insulin pens and used a “hand-over-hand” method during injection. This failure to ensure proper training and delegation in medication administration poses a potential health and safety risk to residents, including risk of injury, infection, or medication error.
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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.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
Control Number 15-AS-20241029121159
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
VISIT DATE: 12/09/2025
NARRATIVE
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LIC9099- C (Page 4)

An exit interview was conducted with Executive Director, Dolly Bindar and the findings of this investigation were discussed. Copies of the LIC 9099, LIC 9099-D, and Appeal Rights were provided to the Licensee during the visit.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5