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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415600964
Report Date: 12/05/2023
Date Signed: 12/05/2023 11:03:06 AM

Unfounded


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
05/18/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230518124015
FACILITY NAME:KENSINGTON PLACE REDWOOD CITYFACILITY NUMBER:
415600964
ADMINISTRATOR:JOAN NEWMANFACILITY TYPE:
740
ADDRESS:2800 EL CAMINO REALTELEPHONE:
(650) 363-9200
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:67CENSUS: 41DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Douglas BlakeTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Facility did not have a call system in place and as a result resident was left on the floor for an extended period of time
- Staff did not provide a care plan for resident
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegation received. LPA met with Douglas Blake, soon to be administrator, and explained the purpose of today's visit.

During the investigation LPA conducted interviews, reviewed pertinent documents, and made facility observations. It is discovered that the facility does not have a pendant system in place but rather pull cords installed in resident rooms. Per observations there is a call system in place. The facility does have a pendant system in place as well and it is provided to residents that are able to use it on their own and based on their assessments. At the time the resident in this complaint resided in the facility they was not able to manage the pendant. The facility did provide one to the resident at the request of the responsible party but it was not utilized and it would often be found not on the resident due to behavior of removing the pendant and at times would throw it or lose it. Regarding not providing a care plan for resident, LPA received the care plan for the resident that was developed and updated through out the time the resident was in the facility and was provided to the responsible party. These allegations are unfounded.

This agency has investigated the above complaints. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint.

Report is reviewed with Douglas Blake.
Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
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
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
05/18/2023 and conducted by Evaluator Jaime Vado
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20230518124015

FACILITY NAME:KENSINGTON PLACE REDWOOD CITYFACILITY NUMBER:
415600964
ADMINISTRATOR:JOAN NEWMANFACILITY TYPE:
740
ADDRESS:2800 EL CAMINO REALTELEPHONE:
(650) 363-9200
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:67CENSUS: 41DATE:
12/05/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Douglas BlakeTIME COMPLETED:
11:10 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
- Resident sustained unexplained bruising while in care
- Staff did not inform resident's authorized representative of change in resident’s condition
- Staff did not elevate resident’s leg in accordance with doctor’s recommendation
- Staff did not assist resident with meeting medical needs
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegation received. LPA met with Douglas Blake, soon to be administrator, and explained the purpose of today's visit.

During the investigation LPA conducted interviews, reviewed pertinent documents, and made facility observations. Regarding the above allegations it was discovered that the resident was combative and refused care at times including the flailing of arms, refusal of care, and other behaviors which may have caused unintentional bruising. Interviews conducted with staff they did communicate with the responsible party regularly and when medical needs arose the staff did inform the responsible party timely. Regarding not elevating the resident's leg, LPA observed the resident being pushed in the facility via wheelchair and the leg was elevated. Interviews also showed that the resident was not compliant with care due to behaviors related to diagnosis and would often refuse to keep their leg being elevated despite staff reminding to elevate and assisting in elevating. Due to no further information being received from incoming complainant these allegations are unsubstantiated.

Based on these observations, the above allegations are UNSUBSTANTIATED.
Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time.

Report is reviewed with Douglas Blake.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: April CowanTELEPHONE: (650) 266-8865
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 12/05/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/05/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 2