079201241-8-7-2024-15-AS-KHOS-D84QQG-20240813122218

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 079201241
Report Date: 08/07/2024
Date Signed: 08/07/2024 07:34:02 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
01/09/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240109150122

FACILITY NAME:	KENSINGTON AT WALNUT CREEK, THE		FACILITY NUMBER:	079201241
ADMINISTRATOR:	BRADLEY, DEBORAH		FACILITY TYPE:	740
ADDRESS:	1580 GEARY ROAD		TELEPHONE:	(925) 973-1121
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	200	CENSUS: 143	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Joseph Villanueva, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

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1. Staff mismanaged residents medication.

INVESTIGATION FINDINGS:

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On 08/07/2024 at 10:30 AM, Licensing Program Analysts (LPAs) L. Alexander and G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPAs met with Executive Director, Joseph Villanueva.

During the course of investigation, LPA L. Alexander interviewed complainant (RP), resident and staff. LPAs obtained and reviewed documents including physician's report, medication administration records (MAR), centrally stored medication (CSMDR) list, physician's mediciation orders, med tech staff schedules.

LIC9099-C Continued...

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

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-20240109150122

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: 08/07/2024

NARRATIVE

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Allegation: Staff mismanaged residents medication.
Substantiated.

On 01/17/2024 LPA spoke with RP that stated that a "pink pill' was pushed on R1. Interview with R1 revealed that on this particular day "a pink" pill was being administered to them and they asked S2 what was the pill. R1 stated that S2 said the pill was the same pill but there was a "different manufacturer". R1 stated that they did not refuse to take the pill. RP stated later R1 found out the "pink pill" was a thyroid medication. On 08/07/2024 LPA interviewed S4 that stated R1 was not on any type of thyroid pill and that R1 was on many different kinds of medications.

LPA reviewed MAR for Sept 2023 and observed R1 was not given insulin Lispro injection for multiple days. There was no documentation explaining those dates R1 missed insulin Lispro injections.

Based on LPA's information obtained during investigation, the preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Title 22, are being cited on the attached LIC9099D.

Exit interview conducted. A copy of this report and appeal rights provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 15-AS-20240109150122

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: 08/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 08/26/2024 Section Cited CCR 87464(f)(4)	1 2 3 4 5 6 7	(f) Basic services shall at a minimum include: (4) Personal assistance and care as needed by the resident...with those activities of daily living such ...assistance with taking prescribed medications. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director has agreed to training for administering medication and submit staff sign in sheet to CCLD by POC date.
	8 9 10 11 12 13 14	Based on investigation, licensee did not comply with the section cited above by not administering medication according to doctor's orders which poses a potential health and safety risk to the persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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 Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
01/09/2024 and conducted by Evaluator Lori Alexander-Washington

PUBLIC

COMPLAINT CONTROL NUMBER: 15-AS-20240109150122

FACILITY NAME:	KENSINGTON AT WALNUT CREEK, THE		FACILITY NUMBER:	079201241
ADMINISTRATOR:	BRADLEY, DEBORAH		FACILITY TYPE:	740
ADDRESS:	1580 GEARY ROAD		TELEPHONE:	(925) 973-1121
CITY:	WALNUT CREEK	STATE: CA	ZIP CODE:	94597
CAPACITY:	200	CENSUS: 143	DATE:	08/07/2024
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Joseph Villanueva, Executive Director		TIME COMPLETED:	06:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

2. Staff does not keep an accurate medication log.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 08/07/2024 at 10:30 AM, Licensing Program Analysts (LPAs) L. Alexander and G. Luk arrived unannounced to conduct complaint investigation and deliver findings in regards to the allegation above. LPAs met with Executive Director, Joseph Villanueva.

During the course of investigation, LPA L. Alexander interviewed complainant (RP), resident and staff. LPAs obtained and reviewed documents including physician's report, medication administration records (MAR), centrally stored medication (CSMDR) list, physician's medication orders, med tech staff schedules.

LIC9099-C Continued...

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 15-AS-20240109150122

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: 08/07/2024

NARRATIVE

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Allegation: Staff does not keep an accurate medication log.
Unsubstantiated.

LPA reviewed Centrally Stored Medication Log and observed that R1 has all medications documented with name of medication, prescription date, number of refills, etc.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview conducted, a copy of this report provided.

SUPERVISOR'S NAME: Bennett Fong	TELEPHONE: (510) 725-7919
LICENSING EVALUATOR NAME: Lori Alexander-Washington	TELEPHONE: (510) 285-3934
LICENSING EVALUATOR SIGNATURE:	DATE: 08/07/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 5