198320032-12-2-2025-11-AS-UCOL-DPH3BC-20251218170607

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 198320032
Report Date: 12/02/2025
Date Signed: 12/02/2025 09:57:23 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/14/2025 and conducted by Evaluator Regina Cloyd

PUBLIC

COMPLAINT CONTROL NUMBER: 11-AS-20251014093150

FACILITY NAME:	KENSINGTON REDONDO BEACH, THE		FACILITY NUMBER:	198320032
ADMINISTRATOR:	MAY, ROBERT		FACILITY TYPE:	740
ADDRESS:	801 S PACIFICA COAST HIGHWAY		TELEPHONE:	(424) 241-2064
CITY:	REDONDO BEACH	STATE: CA	ZIP CODE:	90277
CAPACITY:	132	CENSUS: 115	DATE:	12/02/2025
		UNANNOUNCED	TIME BEGAN:	08:38 AM
MET WITH:	Janie Acosta		TIME COMPLETED:	10:15 AM

ALLEGATION(S):

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Facility staff are not properly reporting incidents.
Facility staff are not ensuring resident receives podiatry care as needed.

INVESTIGATION FINDINGS:

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On 12/02/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with the Director of Nursing Janie Acosta and the purpose of the visit was explained.

Investigation consisted of the following: On 10/24/2025, LPA obtained Personnel Report (dated 10/24/25), Register of Residents, eight resident Clinical View Reports (April 2025 – June 2025) and reviewed ten resident records. LPA interviewed Staff #1 – 12 and toured the Haven neighborhood. On 11/19/25, LPA interviewed Witness #1. On 12/01/25, LPA interviewed Witness 2 – 3, 5, 7. On 12/02/25, LPA interviewed Staff #1, #10, and #13.

Note: LPA left a message for Witness #4, #6, #8, #9, and #10.

Continue to LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

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 3

Control Number 11-AS-20251014093150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KENSINGTON REDONDO BEACH, THE	FACILITY NUMBER: 198320032
	VISIT DATE: 12/02/2025

NARRATIVE

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Allegation: Facility staff are not properly reporting incidents
Regarding the allegation, “facility staff are not properly reporting incidents,” it is being alleged that only two out six falls were reported for Resident #1. It is also alleged that the paperwork was not completed accurately since one fall resulted in an emergency room visit. Record review of clinical view report revealed R1 tripped (03/10/25) and fell (03/28/25; 04/12/25; 04/30/25). Responsible party/parties were notified on all four dates including the incident associated with the emergency room visit (04/12/25). Ten out of ten staff interviews (S2 - S3, S5 – S12) indicated that incidents are reported to the appropriate parties and are documented. Director of Nursing indicated families are contacted, the doctor is informed, and notes are made in the facility’s charting system. Witness #1, R1’s responsible party, indicated that the facility generally calls to report incidents. Four out four witness/responsible party interviews (W2 – W3, W5, W7) indicated that the facility staff report resident incidents.

Regarding the allegation, “facility staff are not properly reporting incidents,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

Allegation: Facility staff are not ensuring resident receives podiatry care as needed.
Regarding the allegation, “facility staff are not ensuring resident receives podiatry care as needed,” it is being alleged that Resident #1 has not received services since 02/24/25. It is alleged that R1’s Physician ordered daily foot care services on 05/16/25 and R1 has yet to receive services as of 10/14/25. Record review of Podiatrist encounter notes revealed R1 received services on 02/24/25, 05/04/25, and 10/10/25. Podiatrist Progress notes revealed R1’s nails were clipped on 09/04/25. Torrance Memorial (05/16/25) note revealed R1 is to receive daily foot care and podiatry evaluation every two months. Torrance Memorial (07/15/25) response note revealed R1’s feet is to be evaluated daily for sores, redness, dryness and to call with abnormal finding and provide nail clipping as needed. Eight out of eight staff interviews (S2, S5 – S7, S9-S12) indicated that residents receive podiatry services once every other month. Director of Nursing/S1 and S3 indicated that care partners do the daily care, notify the nurse, and will request a PRN or scheduled visit. S1 also indicated that R1’s August 2025 podiatry visit was pushed to 09/04/25 due to the Podiatrist’s schedule. S10 and S13 indicated they evaluate R1’s feet and look for redness, bumps, dryness, skin tears, and observe R1’s nail. S10 indicated that most reports are regarding nail length.
Continue to LIC9099-C.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 11-AS-20251014093150

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
EL SEGUNDO ASC, 400 CONTINENTAL BLVD, STE 340
EL SEGUNDO, CA 90245

FACILITY NAME: KENSINGTON REDONDO BEACH, THE	FACILITY NUMBER: 198320032
	VISIT DATE: 12/02/2025

NARRATIVE

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Witness #1, R1’s Emergency Contact, indicated that the facility does have a podiatrist come but R1’s feet are not being cared for enough. W1 indicated that the Practitioner sent a note for daily foot care but W1 is not sure if R1 is receiving it. Four out four witness/responsible party interviews (W2 – W3, W5, W7) indicated that podiatry care is provided to residents. Regarding the allegation, “facility staff are not ensuring resident receives podiatry care as needed” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated.

No deficiencies were cited.

An exit interview was conducted and a copy of this report was provided to the Director of Nursing Janie Acosta.

SUPERVISORS NAME: Ulysses Coronel
LICENSING EVALUATOR NAME: Regina Cloyd
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2025

LIC9099 (FAS) - (06/04)

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