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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 12/18/2025
Date Signed: 12/18/2025 03:27:33 PM

Document Has Been Signed on 12/18/2025 03:27 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/
DIRECTOR:		VILLANUEVA, JOSEPHFACILITY TYPE:
740
ADDRESS:1580 GEARY ROADTELEPHONE:
(925) 973-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 200CENSUS: 147DATE:
12/18/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:55 AM
MET WITH:Ricardo Romero, Sr, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
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On 12/18/2025 at 9:55 a.m., Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding medication related incident reports received by the Community Care Licensing Division (CCLD) on 12/09/2025, 11/20/2025, 10/20/2025 and 07/03/2025. LPA met with Interim Executive Director (ED) Ricardo Romero, Sr and explained the purpose of the visit.

The case management visit was conducted due to multiple Unusual Incident Reports (UIRs) submitted by the facility over several months involving medication administration errors.

CCLD received a UIR regarding an incident that occurred on 12/07/2025, which indicated that Resident (R1) requested a PRN medication for agitation; however, Staff (S1) administered an anti-diarrheal medication instead to R1.

CCLD also received a UIR for an incident that occurred on 11/19/2025 at approximately 5:00 p.m., which indicated that R2 was inadvertently administered the wrong medication during the evening medication pass by S4 and S5. During interviews with S2 and S3, it was stated that the medication error occurred while S5 was training S4.

LIC809-C Continued...

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
VISIT DATE: 12/18/2025
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LIC809-C (Page 2)

Additionally, CCLD received UIRs documenting two medication related incidents that occurred on 10/07/2025 and 10/12/2025. The report for 10/07/2025 indicated that R3 was not administered a prescribed medication patch; however, it was documented and signed by S7 as having been given.

The report for 10/12/2025 indicated that S7 administered a medication to R4 by sprinkling it on food. S7 stepped away after providing the food to R4. Subsequently, a guest consumed the food containing the medication. During interviews with S8, it was stated that when S7 stepped away, R4 offered the food containing the medication to the guest, who was seated at the dining table with another resident.

During interviews conducted on 08/27/2025, S2 and S3 stated they were not aware of any documented follow-up notes or Plan of Correction addressing the medication errors. Both staff reported that the Medication Technician, S7, responsible for administering the incorrect medication was no longer employed at the facility.

CCLD also reviewed a UIR regarding an incident that occurred on 07/03/2025, which indicated that R5, all memory care residents, missed their morning medications due to staffing issues after S9 tested positive for COVID-19 and left the facility. The report further stated that S10 from another community arrived to assist; however, the time window for the morning medication pass had elapsed.

LPA obtained the following documents: R4's physician's report (LIC602-A), fax confirmation requesting an updated LIC602-A (dated 10/15/25), doctor's orders for crushed/sprinkled medications in foods/liquids and copy of S9's time card (dated 07/01/25 thru 07/10/25).

As a result of the above findings, deficiencies were observed (see LIC 809D) and cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

An exit interview was conducted, and a copy of this report along with appeal rights was provided.

NAME OF LICENSING PROGRAM MANAGER: Bennett Fong
NAME OF LICENSING PROGRAM ANALYST: Lori Alexander-Washington
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 12/18/2025 03:27 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 12/18/2025 at 10:40 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 12/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/19/2026
Section Cited
CCR
87465(c)(2)

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CCR 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.
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Administrator shall have all staff that administer medications to complete a 4hrs minimum Medication Training course with an approved CDSS vendor.

Repeat Violation Civil Penalty $250.00
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Based on record review and interviews, the licensee did not comply with section above by not administering medications to residents (i.e., R1, R2, R3, R4, R5) according to the physician's directions which poses a potential health and safety risk to the persons in care.
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Course topics shall cover Medication Administration including but not limited to documentation procedures, narcotics, injections, enemas, suppositories, missed and medication errors. Completed certificates will be submitted to CCLD by POC due date.

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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.
Bennett Fong
NAME OF LICENSING PROGRAM MANAGER:
Lori Alexander-Washington
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/18/2025


LIC809 (FAS) - (06/04)
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