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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600964
Report Date: 08/18/2019
Date Signed: 08/18/2019 04:20:07 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME:KENSINGTON PLACE REDWOOD CITYFACILITY NUMBER:
415600964
ADMINISTRATOR:VALENCIA, BRANDYFACILITY TYPE:
740
ADDRESS:2800 EL CAMINO REALTELEPHONE:
(650) 363-9200
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:67CENSUS: 58DATE:
08/18/2019
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Joanne Hubbard, Executive DirectorTIME COMPLETED:
04:30 PM
NARRATIVE
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On 8/18/2019 at 9:05AM, Licensing Program Analyst (LPA) Grace Luk arrived unannounced and conducted a Required 1 Year inspection. LPA was greeted by concierge, Yareli Miranda. Executive Director, Joanne Hubbard arrived 40 minutes later. The facility’s fire clearance was approved for 67 non-ambulatory residents of which 20 may be bedridden and 20 may be under hospice care.

With Executive Director, LPA toured the facility including but not limited to 8 resident bedrooms, bathrooms, activity room, dining area, kitchen, laundry, medication room, and other common areas. Centrally stored medications were locked in different carts on both floors. PRN medications have written orders from a physician. The facility has a written emergency disaster plan. Smoke detectors were interconnected with sprinkler system. Cintas Fire Protection performed a sprinkler system check on 8/5/2019 and fire inspection was completed on 5/22/2019. Fire extinguishers were observed to be full and lasted inspected on 1/19/2019. Various activities were conducted for the residents during visit. Facility is a memory care community with the exit doors equipped with delayed egress. Last fire drill was conducted on 7/22/2019.

One week supply of nonperishable and 2-day supply of perishable foods were available. Comfortable temperature was maintained inside the facility and measured at 74 degrees Fahrenheit. Hot water temperature was measured at 109.6 degrees F in one of the bathrooms. Freezer’s temperature was registered at 0 degree F while the refrigerator’s temperature was recorded at 40 degrees F. There were adequate lights in each room. Hallways and passages were free of obstruction. All resident's bathrooms have grab bars for each toilet/shower area and non-skid material in shower.

(Continue on LIC809C...)
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2019
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: KENSINGTON PLACE REDWOOD CITY
FACILITY NUMBER: 415600964
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/19/2019
Section Cited
CCR
87705(f)(2)
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Care of Persons with Dementia. The following shall be stored inaccessible to residents with dementia: Over-the-counter medication,...cleaning supplies and disinfectants. This requirement
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Administrator removed and locked the OTC medications, cleaning supplies, and other dangerous items during inspection.

Deficiency cleared during inspection.
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is not met as evidence by:
Based on observation, licensee failed to keep over-the-counter medication, cleaning supplies, and other dangerous items inaccessible which poses an immeidate health and safety risk to the residents in care.
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Type B
08/24/2019
Section Cited
CCR
87555(b)(24)
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General Food Service Requirements.Pesticides and other toxic substances shall not be stored in food storerooms, kitchen areas... This requirement is not met as evidence by:
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Staff removed emergency food supplies and stored it in a separate storage room during inspection.

Deficiency cleared during inspection.
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Based on observation, licensee failed to keep paint supplies stored separate from food supplies which poses a potential health and safety risk to the residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2019
LIC809 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA
FACILITY NAME: KENSINGTON PLACE REDWOOD CITY
FACILITY NUMBER: 415600964
VISIT DATE: 08/18/2019
NARRATIVE
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8 residents' records and 8 staff records were reviewed starting at 11:00AM. Residents' records contained signed Admission Agreement, needs & service plan, and emergency information. All staff are fingerprint cleared and associated to the facility. LPA reviewed a sample of resident's medication and medication log. PRN medications have physician's order.

At 9:50AM, LPA observed a bottle of surface cleaner in R1's an unlocked drawer. LPA observed unlocked over-the-counter medication, nasal spray, and eye drops in R8's cabinet.

At 10:20AM, LPA observed emergency food supplies stored in the same area as paint supplies. Staff moved emergency food supplies in a separate storage room during inspection.

At 11:45AM, LPA observed S4 does not have current first aid training during record review. S4 has an LVN license expires 10/31/2020; however, it shows that the license is inactive.

At 12:45AM, LPA observed R3 does not have TB test on file and R2 & R8 does not have current medical assessment on file during record review.

At 1:30PM, LPA observed R1, R3, R4, and R7 does not have physician's order for half bed rails on file during record review.

The deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22. Failure to correct the deficiencies may result in civil penalties.

The following shall be updated and submitted to the Licensing by 9/7/2019:
LIC 500 (Personnel Record)
LIC 610E (Emergency Disaster Plan)

Exit interview conducted. A copy of this report and appeal rights provided.
SUPERVISOR'S NAME: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2019
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2019
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: KENSINGTON PLACE REDWOOD CITY
FACILITY NUMBER: 415600964
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2019
Section Cited
CCR
87705(c)(5)
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Care of Persons with Dementia. Each resident with dementia shall have an annual medical assessment as specified in Section 87458... This requirement is not met as evidence by:
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Administrator has agreed to obtain current medical assessment for R2 and R8. Administrator will submit a copy of each to CCLD by POC date.
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Based on record review, licensee failed to have current medical assessment for R2 and R8 which poses a potential health and safety risk to the residents in care.
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Type B
09/07/2019
Section Cited
CCR
87458(b)(1)
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Medical Assessment. A physical examination of the resident indicating the physician's primary diagnosis and...results of ...communicable tuberculosis... This requirement is not me as
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Administrator has agreed to obtain TB test results for R3 and submit a copy to CCLD by POC date.
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evidence by: Based on record review, licensee failed to have R3's TB test result which poses a potential health and safety risk to the residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2019
LIC809 (FAS) - (06/04)
Page: 5 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office,
, CA

FACILITY NAME: KENSINGTON PLACE REDWOOD CITY
FACILITY NUMBER: 415600964
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/18/2019
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/07/2019
Section Cited
CCR
87411(c)(1)
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Personnel Requirements - General. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement is not met as evidence
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Administrator has agreed to obtain current first aid training for S4 and submit a copy to CCLD by POC date.
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by: Based on record review, licensee failed to have current first aid training for S4 which poses a potential health and safety risk to the residents in care.
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Type B
09/07/2019
Section Cited
CCR
87608(a)(3)
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Postural Supports. A written order from a physician indicating the need for the postural support shall be maintained in the resident’s record. This requirement is not met as evidence by:
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Administrator has agreed to obtain physician's order for R1, R3, R4, and R7's half bed rails and submit a copy of each to CCLD by POC date.
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Based on record review, licensee failed to have physician's orders for R1, R3, R4, and R7's half bed rails which poses a potential health and safety risk to the residents in care.
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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: Harpreet HumpalTELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Grace LukTELEPHONE: (510) 286-4201
LICENSING EVALUATOR SIGNATURE:

DATE: 08/18/2019
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/18/2019
LIC809 (FAS) - (06/04)
Page: 4 of 5