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Inspection visit

Incident investigation

KENSINGTON AT WALNUT CREEK, THELicense 0792012411 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

On 08/27/2025 at 3:30 PM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit in regards to incident reports received to Community Care Licensing Division (CCLD) on 06/23/2025. LPA met with Assistant Executive Director, Deborah Bradley and Interim Executive Director, Ricardo Romero and informed the reason for visit. On 06/23/2025 CCLD received two Unusual Incident Reports (UIR) that occurred on 06/16/25 and 06/18/25. The incident report indicated that resident (R) R1 left the community by themself through one of the backdoors. The report further indicated that the front desk reviewed the cameras and saw R1 crossing the street, on the sidewalk coming from the east side of building and also coming from the shopping center back to the community. The writer stated on the report that R1's Wander Guard did not go off. The UIR that occurred on 06/18/25 indicated that R1 left the community by themself through one of the backdoors again. The writer of this report stated that R1's Wander Guard went off. The report further stated that a RA was able to direct R1 back inside the community. On 08/27/2025 LPA L. Alexander interviewed S1 that stated they have been having conversations with R1's family regarding the elopements and suggested a 1:1 companion and memory care. S1 stated that the family started 1:1 companion on 06/18/2025 later that evening. LIC809-C Continued LIC809-C (Page 2) On 08/27/2025 LPA L. Alexander reviewed R1's physician's report (dated 03/21/23) that indicates R1 is not able to leave the facility unassisted and also has a diagnosis of dementia. 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.

Citations

4 citations recorded*CCLD

What does Type A vs Type B mean?

Type A. Serious citation. Imminent or substantial risk to children. The regulator requires corrective action immediately and may impose a civil penalty.

Type B. Lower-severity citation. Corrective action required, no imminent risk. The regulator monitors compliance on the next visit.

  • 87468.2(a)(4)Type B

    87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff that are sufficient in numbers, qualifications, and competency to meet their needs.This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not reporting R1's elopement within the next day to Licensing which poses a potential health, safety or personal rights risk to persons in care.

  • 87211(a)(1)Type B

    87211 Reporting Requirements(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events... This report shall include the resident's name...This requirement is not met as evidenced by: Based on record review, the licensee did not comply with the section cited above in by not submitting a written report within 7 days of the occurences of any of the events for residents in care. Reports received to CCLD were dated 11/15/24, 11/12/24 and 12/1/24 as an example and were received on 01/02/25 which poses a potential health, safety or personal rights risk to persons in care.

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  • 1569.683(a)(3)Type B

    §1569.683 Eviction notices (a) In addition to complying with other applicable regulations, a licensee of a residential care facility for the elderly who sends a notice of eviction to a resident...with specific facts to permit the notice to quit shall include all of the following: (3) Information about the resident's right to file a complaint...with the name, address, and telephone number of the nearest office of.. the State Ombudsman.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not sending the notice to evict with the correct contact information for the local Ombudsman to R1's responsible party which poses a potential health, safety or personal rights risk to persons in care.

  • 87465(c)(2)Type B

    87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions.This requirement is not met as evidenced by: Based on record review and interview, the licensee did not comply with the section cited above in by not administering medication for R1 ordered by the physician and given according to the physician's directions which poses a potential health, safety or personal rights risk to persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the August 27, 2025 inspection of KENSINGTON AT WALNUT CREEK, THE?

This was a other inspection of KENSINGTON AT WALNUT CREEK, THE on August 27, 2025. 1 citation were issued: 1 Type B.

Were any citations issued to KENSINGTON AT WALNUT CREEK, THE on August 27, 2025?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "87468.2 Additional Personal Rights of Residents in Privately Operated Facilities (a) In addition to the rights listed in..."

What type of inspection was this?

This was a other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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