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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600964
Report Date: 03/12/2025
Date Signed: 03/12/2025 10:43:39 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/30/2025 and conducted by Evaluator John Calandra
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250130121349
FACILITY NAME:KENSINGTON PLACE REDWOOD CITYFACILITY NUMBER:
415600964
ADMINISTRATOR:ALBERTO GOLIAFACILITY TYPE:
740
ADDRESS:2800 EL CAMINO REALTELEPHONE:
(650) 363-9200
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:67CENSUS: 57DATE:
03/12/2025
UNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH: Carol Blackwell, Director of NursingTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Facility is not providing updates regarding R1s care needs to responsible party.
Facility is not meeting R1s care needs in regard to ADLs.
INVESTIGATION FINDINGS:
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On 3/12/2025, Licensing Program Analyst (LPA) John Calandra met with Carol Blackwell, Director of Nursing for this conclusionary complaint inspection. On 2/6/2025, LPA conducted initial complaint inspection and conducted interviews and reviewed resident records.

LPA later gathered more information regarding the above allegations regarding possible personal rights and level of care violations. The resident (R1) in this complaint no longer resides at the facility and has been unable to be interviewed and no further information has been able to be obtained by complainant. Based on information gathered from facility and review of resident records and interviews conducted, it was determined facility conducted the required resident appraisal upon admission to facility. LPA checked and reviewed subsequent resident reappraisals, and it was found that the care needs of R1 were being met until an incident occurred in which R1 displayed a change of behavior, however facility was unable to do a follow up appraisal because R1 had not returned to the facility after responsible party removed
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
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 2
Control Number 14-AS-20250130121349
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 CITY
FACILITY NUMBER: 415600964
VISIT DATE: 03/12/2025
NARRATIVE
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resident from facility. Since facility could not reappraise R1 after an incident, it is unknown the level of care that may have been needed.

Based on the Department's investigation, it was determined there was a lack of sufficient evidence to support or deny the allegations. Based on this information, the findings of these allegations are unsubstantiated.

This report was reviewed and discussed with facility representative and a copy of this report must be made available for public review upon request.

SUPERVISORS NAME: Andrea Medlin
LICENSING EVALUATOR NAME: John Calandra
LICENSING EVALUATOR SIGNATURE:

DATE: 03/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2