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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415600964
Report Date: 12/27/2024
Date Signed: 12/27/2024 10:54:33 AM

Document Has Been Signed on 12/27/2024 10:54 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:KENSINGTON PLACE REDWOOD CITYFACILITY NUMBER:
415600964
ADMINISTRATOR/
DIRECTOR:		ALBERTO GOLIAFACILITY TYPE:
740
ADDRESS:2800 EL CAMINO REALTELEPHONE:
(650) 363-9200
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY: 67CENSUS: 54DATE:
12/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Alberto Golia, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
11:00 AM
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On 12/27/2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 AM to conduct a Case Management visit for the purpose of following up on a self-reported incident and met with Jessi Kaur, Memory Care Director and Alberto Golia, Executive Director. LPA was informed that on 12/19/2024, R1 had wandered out of the facility unassisted. R1 was found several minutes after staff were aware of their absence and located R1 approximately 1 block away with no signs of injury or change of condition. Upon file review, R1 is not able to the facility unassisted.

The facility is aware of R1's wandering behavior and did an elopement drills with all staff on all shifts on 12/19/2024. Furthermore, the facility has taken additional steps to ensure more individualized activities to keep R1 engaged. LPA found that facility is taking appropriate preventative measures to ensure R1 is provided individualized updates on supervision. Lastly, the facility is ensuring all residents are properly supervised and engaged moving forward.

Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties.

An exit interview was conducted. This report was reviewed with Alberto Golia, Executive Director and a copy of the report along with Appeal Rights left at the facility.



SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE: DATE: 12/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/27/2024
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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Document Has Been Signed on 12/27/2024 10:54 AM - It Cannot Be Edited


Created By: John Calandra On 12/27/2024 at 09:49 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KENSINGTON PLACE REDWOOD CITY
FACILITY NUMBER: 415600964

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/27/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/10/2025
Section Cited
CCR
87411(a)

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87411 a) Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs.

This requirement is not met as evidenced by:
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Facility has implemented additional precautionary measures including conducting additional staff elopement training and implemented personnel changes. LPA found that the facility has take appropriate measures for plan of corrections. Deficiency cleared at the time of visit.
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Based on record review and interview, the facility did not ensure that basic services such as care and supervision were being met which resulted in R1 AWOL. Furtheremore, the concierge has been transitioned to another department within the facility. This serves as a potential health, safety, or personal rights risk to persons 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:Andrea Medlin
LICENSING EVALUATOR NAME:John Calandra
LICENSING EVALUATOR SIGNATURE:
DATE: 12/27/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/27/2024


LIC809 (FAS) - (06/04)
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