415600964-7-29-2020-14-AS-JMOS-BSFT33-20200813142138

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 415600964
Report Date: 06/25/2020
Date Signed: 07/29/2020 03:17:10 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
01/13/2020 and conducted by Evaluator Bertha Raygoza

PUBLIC

COMPLAINT CONTROL NUMBER: 14-AS-20200113115912

FACILITY NAME:	KENSINGTON PLACE REDWOOD CITY		FACILITY NUMBER:	415600964
ADMINISTRATOR:	VALENCIA, BRANDY		FACILITY TYPE:	740
ADDRESS:	2800 EL CAMINO REAL		TELEPHONE:	(650) 363-9200
CITY:	REDWOOD CITY	STATE: CA	ZIP CODE:	94061
CAPACITY:	67	CENSUS: 59	DATE:	06/25/2020
		UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Joanne Hubbard, Administrator		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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- Facility staff is not allowing resident to have visitors
- Facility did not properly address resident's physically violent behavior(s)
- Facility staff released confidential information regarding a resident to an unauthorized individual
- Facility staff did not assist resident(s) in a timely manner
- Lack of supervision resulting in resident biting another resident in care

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Raygoza conducted a subsequent complaint tele-visit investigation regarding the above allegations. LPA delivered an amended report as a result of supervisory review. LPA Raygoza spoke to Administrator, Joanne Hubbard and stated purpose of tele-visit.

- Facility staff is not allowing resident to have visitors
The information and documentation collected by the Department indicate that a visitor upon visiting facility became disruptive and abusive during visit on October 31, 2019. On that day, the visitor became aggressive, loud, demanding and disruptive. Five out of Five staff members and available information revealed that the visitor's disruptive behavior affected other residents and staff on October 31, 2019 and thereafter during visits of 12/31/19 and 1/1/2020. During investigation, LPA interviewed five staff members and all confirmed to have witnessed disruptive behaviors such as loud/yelling voice, disrupting the environment, causing a scene and making demands on staff. Complainant denied those claims and stated that visitor was acting in a calm, serene manner and not causing any scenes.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 14-AS-20200113115912

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066

FACILITY NAME: KENSINGTON PLACE REDWOOD CITY	FACILITY NUMBER: 415600964
	VISIT DATE: 06/25/2020

NARRATIVE

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LPA collected statements and other documents from witnesses and involved parties that confirm that the visitor had disruptive behavior on 12/31/19 and 1/1/2020. Therefore, on January 1, 2020 the visitor was removed from facility for trespassing. Residents shall have visitors provided that the rights of other residents are not infringed upon. While there are visitor's rights, it is not an absolute right. Disruptive visitor's behavior infringes on the rights of other residents. On 4/20/2020, LPA interviewed R1, but due to the resident's health condition no relevant information was forthcoming.

Based on the information and documentation collected, this allegation was determined unsubstantiated. Although, the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the allegation was UNSUBSTANTIATED.

- Facility did not properly address resident's physically violent behavior(s). During the investigation, three out of three staff interviews stated that violent behaviors are addressed and reported as required. Three out of three staff interviewed stated that behaviors caused by dementia residents were appropriately addressed, redirected in a timely manner and Incident reports submitted to CCL Office. LPA confirmed and reviewed those incident reports, the review confirmed staff addressed incidents, physician was contacted and plan of care was in place. Therefore, the allegation is unsubstantiated.

- Facility staff released confidential information regarding a resident to an unauthorized individual. During the investigation, three out of three staff interviews stated Director of Nursing and staff followed all protocol on not releasing confidential information in regards to HIPAA regulations. Rumors and talk amongst visitors are not a source of releasing information. The complainant was unable to provide a verifiable breach of the protocol. Due to the allegation not based on facts but rather rumors, the allegation is unsubstantiated.

- Facility staff did not assist resident(s) in a timely manner. During the investigation, three out of three staff interviews and incident reports confirmed staff assisting residents in a timely manner. The complainant was unable to provide a verifiable breach of the protocol. Therefore, the allegation is unsubstantiated.

- Lack of supervision resulting in resident biting another resident in care. Based on record review, there was an incident of R2 biting R3 and the incident was reported to CCL Office. It appears there was proper protocol that was followed and a plan in place for a non-reoccurrence. Three out of three staff members interviewed stated that the incident was properly addressed and care plan developed to address the behavior. Therefore, the allegation is unsubstantiated.

Although the above allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur. Therefore, the allegations are deemed UNSUBSTANTIATED.

SUPERVISOR'S NAME: Brenda Chan	TELEPHONE: (650) 266-8889
LICENSING EVALUATOR NAME: Bertha Raygoza	TELEPHONE: (650) 266-8833
LICENSING EVALUATOR SIGNATURE:	DATE: 06/25/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/25/2020

LIC9099 (FAS) - (06/04)

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