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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 08/07/2024
Date Signed: 08/07/2024 07:36:39 PM

Document Has Been Signed on 08/07/2024 07:36 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
E BAY DELTA AC/SC, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:KENSINGTON AT WALNUT CREEK, THEFACILITY NUMBER:
079201241
ADMINISTRATOR/
DIRECTOR:		VILLANUEVA, JOSEPHFACILITY TYPE:
740
ADDRESS:1580 GEARY ROADTELEPHONE:
(925) 973-1121
CITY:WALNUT CREEKSTATE: CAZIP CODE:
94597
CAPACITY: 200CENSUS: 143DATE:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
06:00 PM
MET WITH:Joseph Villanueva, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
07:45 PM
NARRATIVE
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On 08/07/2024 at 6:00 PM Licensing Program Analysts (LPAs) L. Alexander and G. Luk conducted an unannounced Case Management inspection. LPAs met with Executive Director, Joseph Villanueva and explained the purpose of the visit.

While LPAs were at the facility for a complaint investigation, the following deficiency were observed.

It was noted in the MAR on 9/24/2023, S1 administered insulin to R1. S1 is not a skilled professional. R1's physician's report states that R1 is unable to administer own injections.

The deficiency was observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiency may result in civil penalties.

Exit interview conducted. A copy of this report and appeal rights provided
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 08/07/2024 07:36 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 08/07/2024 at 06:41 PM
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
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: KENSINGTON AT WALNUT CREEK, THE
FACILITY NUMBER: 079201241

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Request Denied
Type B
08/26/2024
Section Cited
CCR
87629(b)(1)

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Injections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance. This requirement is not met as evidence by:
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Executive Director has agreed to conduct training for staff on injection regulations and submit staff sign in sheet to CCLD by POC date.
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Based on investigation, licensee did not comply with section cited above by having a staff inject insulin for R1 which poses a potential health and safety risk to the 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:Bennett Fong
LICENSING EVALUATOR NAME:Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
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