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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 11/06/2024
Date Signed: 11/06/2024 09:28:53 PM

Document Has Been Signed on 11/06/2024 09:28 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: 164DATE:
11/06/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Joseph Villanueva, Executive DirectorTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
NARRATIVE
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On 11/06/2024 at 3:00 PM Licensing Program Analysts (LPAs) L. Alexander and D. Doidge conducted an unannounced Case Management visit regarding an Unusual Incident Report (UIR) that was reported to CCLD on 10/24/24. LPAs met with Executive Director (ED), Joseph Villanueva, and explained the purpose of the visit.

The incident report indicated that R1 eloped Memory Care (MC) unit on 10/19/24 at around 2:00pm. LPAs interviewed S1 and S2 that observed R1 walking down the street. S1 and S2 stated that they were just arriving for their shift before 2pm and noticed someone that looked familiar. S2 stated that they recognized R1 walking across the street towards Sprouts Farmers Market and started running towards them to direct them back to the facility. S1 stated that they informed S3 that R1 had eloped down the street. LPAs interviewed S3 that stated that they got on their radio and informed MC of the eloped resident and the MC care staff came out to look for R1 and direct them back to the facility. LPAs interviewed S4 that stated that R1 walked out the egress door which is located on the east side of the building. S4 stated that the plate was stuck which is why the alarm and lights did not go off. S4 stated that they re-adjusted the Maglock and the door was fixed.

LPAs obtained the following documents: physician's report, care plan, memory care staff schedule for 10/19/24 and maintenance work order for 10/18/24.

The following deficiencies were observed (see LIC 809D) and cited from the California Code of Regulations, Title 22 and/or Health and Safety Code Failure to correct deficiencies by POC date may result in additional Civil Penalties.

Exit interview conducted. Appeal Rights and a copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/06/2024
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 11/06/2024 09:28 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/06/2024 at 04:57 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: 11/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/22/2024
Section Cited
CCR
87303(a)

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87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors
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Administrator agrees to have the egress doors checked by maintenance twice a day and documented. Administrator will train all associates to confirm egress is functional after walking through doors.
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This requirement is not met as evidenced by:

Based on interview, the licensee did not comply with the section cited above in by not having egress doors working properly in Memory Care to prevent residents (R1) from eloping the facility which posed an immediate health and safety risk to persons in care.

Repeat Violation assessed civil penalty $250.00
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Administrator will submit to CCLD by POC due date.
Type B
11/22/2024
Section Cited
CCR87705(k)(8)

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87705 Care of Persons with Dementia
(k) The following initial and continuing requirements must be met for the licensee to utilize delayed egres devices on exterior doors or perimeter fence gates:
(8) Delayed egress devices shall not substitute for trained staff in sufficient numbers to meet the care and supervision needs of all residents and to escort residents who leave the facility.
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Administrator agrees to conduct a re-training on elopement with all staff and will review staff schedules to ensure overlapping between shifts.
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This requirement is not met as evidenced by:

Based on interview, the licensee did not comply with the section cited above in by not having trained staff to meet the care and supervision needs for residents (R1) eloping from Memory Care which posed an immediate health and safety risk to persons in care.
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Administrator will submit in-training sign-in sheet and updated staff schedules to CCLD by POC due date.
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: 11/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/06/2024


LIC809 (FAS) - (06/04)
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