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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 04/24/2024
Date Signed: 04/24/2024 05:46:50 PM


Document Has Been Signed on 04/24/2024 05:46 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:
04/24/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Joseph Villanueva, Executive DirectorTIME COMPLETED:
01:15 PM
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On 04/24/2024 at 12:45 PM Licensing Program Analyst (LPA) Lori Alexander conducted an unannounced Case Management visit regarding an incident of Suspected Elder Abuse (SOC342) that was cross reported to CCLD on 02/23/2024 from Adult Protective Services. LPA met with Executive Director, Joseph Villanueva, and explained the purpose of the visit.

The incident report indicated that on 01/25/2024 care staff reported to "Direct" that a caregiver (S1) on 01/23/2024 was yelling at a resident (R1) who is in memory care. The report indicated that S1 yelled at R1 to "be quiet or she would give her a cold shower." The report further indicated that S1 "roughly" placed R1's walker in front of them and told them to "go."

LPA interviewed S2 who confirmed the incident and that S1 was placed on paid administrative leave pending further investigation by Human Resources and their Regional Human Resources. S2 stated that during the investigation they substantiated the allegation with the corroboration statements from other caregivers and witnesses in the memory care unit. S2 stated that S1 was terminated on 02/02/2024.

No deficiencies issued during the visit.

Exit interview conducted and a copy of this report was provided.
SUPERVISOR'S NAME: Bennett FongTELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-WashingtonTELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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