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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 10/26/2023
Date Signed: 10/26/2023 03:43:08 PM


Document Has Been Signed on 10/26/2023 03:43 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:BRADLEY, DEBORAHFACILITY TYPE:
740
ADDRESS:1580 GEARY ROADTELEPHONE:
(925) 973-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY:200CENSUS: DATE:
10/26/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:25 PM
MET WITH:Joseph Villanueva, Executive DirectorTIME COMPLETED:
03:50 PM
NARRATIVE
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On 10/26/2023 at 2:25PM Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a Case Management visit to follow-up on a death report received by Community Care licensing. LPA met with Joseph Villanueva (ED) and Deborah Bradley, Assistant Executive Director (AED) and explained the purpose of the visit. Executive Director had to continue a staff meeting. However, the Assistant Executive Director met with LPA to discuss the incident.

R1 passed away on 10/12/2023 with an unknown cause of death. During today's visit LPA obtained additional information pertaining to R1's death:

  1. Death Report
  2. Physician's Report Dated 06/24/19
  3. Needs and Services Plan
  4. Level of Care Notification/Care Plan 08/22/23
  5. Care Plan
  6. Prescribed Medication
  7. Residence and Care Agreement
  8. Chart Notes

LPA requested from facility a copy of R1's death certificate and also a copy of the police report.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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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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: 10/26/2023
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LIC 809 Continued....

LPA was informed by Assistant Executive Director that family will provide R1's death certificate, once available and will provide CCL a copy.

No deficiencies cited during this visit. Exit interview conducted 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: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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