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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198320032
Report Date: 04/10/2023
Date Signed: 04/10/2023 12:47:37 PM


Document Has Been Signed on 04/10/2023 12:47 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
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754



FACILITY NAME:KENSINGTON REDONDO BEACH, THEFACILITY NUMBER:
198320032
ADMINISTRATOR:MAY, ROBERTFACILITY TYPE:
740
ADDRESS:801 S PACIFICA COAST HIGHWAYTELEPHONE:
(424) 241-2064
CITY:REDONDO BEACHSTATE: CAZIP CODE:
90277
CAPACITY:132CENSUS: 117DATE:
04/10/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:05 AM
MET WITH:Amy Adam, RNTIME COMPLETED:
12:00 PM
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LIcensing Program Analyst (LPA) Ana Soto conducted an initial case management visit to the above facility. LPA met with Amy Adam, RN and the purpose of the visit was explained.

LPA interviewed RN, R#1 was on many different medication and NP was working with R#1 to minimize and adust medications. R#1 got very aggressive with S#1 and S#1 could not control or calm R#1 down. S#1 was fine did not sustain any injuries. Family member was called and advised of R#1 aggressive behavior and that they would be calling paramedics and Police Department for possible 51/50 hold. Police Officers could not place R#1 on a 5150, because of his mental condition and age. R#1 was taken to Torrance Memorial Medical Center. R#1 never returned to facility, R#1 stayed at the hospital. Family came to the facility to inform them that R#1, was placed on hospice at the hospital and had passed away on 02/08/23. LPA obtained the following records: Medical notes from NP, In-house incident report, Medication, list, Physician's report, Pre -Admission agreement form, Preplacement appraisal, and ID/Emergency information,

An exit interview conducted with Amy Adam, RN and copy of report provided.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ana SotoTELEPHONE: (323) 383-8284
LICENSING EVALUATOR SIGNATURE:
DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/10/2023
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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