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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 079201241
Report Date: 11/19/2024
Date Signed: 11/19/2024 06:55:53 PM

Document Has Been Signed on 11/19/2024 06:55 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:
11/19/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:30 PM
MET WITH:Joseph Villanueva, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 11/19/2024 at 2:30pm, Licensing Program Analysts (LPAs), L. Alexander and L. Hall arrived unannounced to conduct a case management visit. LPAs met with Joseph Villanueva, Administrator and explained the reason for the visit.

While LPAs were conducting a complaint investigation #15-AS-20241029121159 on 11/19/2024, LPAs observed during record review two (2) staff were not fingerprinted and associated to the facility. S2 stated she's interim and from the home office. S5 stated she has been employed with the facility for seven (7) years. LPA ran a guardian search to confirm.

The deficiency is cited per Title 22 California Code of Regulations and listed on LIC809D. Failure to submit proof of corrections (POC) by plan of correction due date and/or any repeat deficiencies within a 12-month period may result in civil penalties.

Exit interview conducted. A copy of the appeal rights, LIC and this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Lori Alexander-Washington
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 11/19/2024 06:55 PM - It Cannot Be Edited


Created By: Lori Alexander-Washington On 11/19/2024 at 06:05 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: 11/19/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/20/2024
Section Cited
CCR
87355(d)

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(d) All individuals subject to criminal record review shall be fingerprinted and sign a Criminal Record Statement (LIC 508 [Rev. 1/03]) under penalty of perjury. This requirement was not met as evidence by:
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Administrator agreed to have S2 and S5 fingerprinted and submit document to CCLD by POC date.
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Based on LPAs observation and record review the Licensee did not comply with the section cited above in having S2 and S5 fingerprinted and associated to facility, which poses a potential health and safety risk to 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: 11/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/19/2024


LIC809 (FAS) - (06/04)
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