Inspection visit

complaintDecember 9, 2025

KENSINGTON AT WALNUT CREEK, THELicense 0792012412 citations on this visit

2 citations recorded

Inspector’s narrative

What the inspector wrote

LIC9099- C (Page 2) Allegation: Staff mismanaged residents’ medications. Finding: Substantiated On 11/09/2024, Licensing Program Analyst (LPA) L. Alexander conducted interviews and reviewed facility records. During the interview, Witness (W1) stated that Resident 1 (R1) has cancer and is prescribed morphine 15mg. W1 reported that staff document the medication as administered multiple times when it was never actually given. W1 stated that R1 is often in significant pain due to missed doses. W1 further alleged that staff select “Exception” within the QMAR system and note “on hand” even when the medication is unavailable. LPA reviewed R1’s physician’s orders, which indicated that morphine 15mg is to be administered one tablet by mouth three times daily (9:00 a.m., 12:00 p.m., and 6:00 p.m.). Review of R1’s October 2024 Medication Administration Record (MAR) revealed missing doses on 10/14/24, 10/15/24, 10/16/24, and 10/18/24. Staff 2’s (S2) chart note on 10/16/24 stated, “waiting on pharmacy to deliver not on hand.” The MAR reflects that on 10/14/24, morphine was administered at 6:00 a.m. and 2:00 p.m., and on 10/15/24, at 6:00 a.m. and 10:00 p.m., with the 2:00 p.m. dose omitted. Allegation: Staff falsified medication administration records. Finding: Substantiated LPA reviewed Resident 2’s (R2) physician’s orders, which included a narcotic to be administered one pill by mouth every eight (8) hours. LIC9099-C Continued... LIC9099- C (Page 3) The Medication Administration Record (MAR) dated 10/18/2024 shows that Staff 1 (S1) documented administering the narcotic at 6:00 a.m., and Staff 2 (S2) documented administration at 2:00 p.m. However, the Individual Resident Narcotic Record indicates that S1 administered the medication at 6:00 a.m., and S2 signed for administration of the same medication at 7:00 a.m. Allegation: Licensee does not ensure staff administering medication to residents are appropriately trained. Finding: Substantiated W1 stated that Med Techs are still administering insulin injection medications to residents. LPA reviewed R2’s physician’s reports, physician’s orders, care plan, MAR (Sept-Nov 24; Aug-Oct ’25) and it shows that R2 cannot administer their own injections. The MARs reveal that Med Techs were administering injections and checking blood glucose via finger stick. On 10/16/2025 LPAs L. Alexander and K. Nguyen interviewed R2 and S1. R2 stated that they are not on insulin and that the Med Techs do not inject them. R2 has a diagnosis of dementia and physician’s orders clearly states insulin injections and blood glucose checks. S1 stated that Med Techs are not doing the insulin injections, but they are setting the PEN up for R2 and that R2 is injecting themselves. LPA asked S1 if they are using the “hand or hand” method and S1 confirmed yes. LIC9099- C (Page 4) An exit interview was conducted with Executive Director, Dolly Bindar and the findings of this investigation were discussed. Copies of the LIC 9099, LIC 9099-D, and Appeal Rights were provided to the Licensee during the visit.

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.

87465(g)Type B
CCR 87465 Incidental Medical and Dental Care(g) The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not activating 9-1-1 if an injury or other circumstance which poses a potential health and safety risk to the persons in care.
87465(a)(6)Type B
CCR 87465(a)(6) – Incidental Medical and Dental CareWhen requested by the prescribing physician or the Department, a record of dosages of medications which are centrally stored shall be maintained by the facility.This requirement was not met as evidenced by: Based on record review and interviews, the licensee failed to ensure accurate medication administration documentation for R2. On 10/18/2024, the MAR reflected narcotic administration times of 6:00 a.m. and 2:00 p.m., while the Individual Resident Narcotic Record showed administration at 6:00 a.m. and 7:00 a.m. The discrepancy between the two documents demonstrates falsified or inaccurate medication administration documentation which poses a potential health and safety risk to the persons in care.
87629(b)(1)Type B
CCR 87629(b)(1) InjectionsInjections. Ensuring that injections are administered by an appropriately skilled professional should the resident require assistance.This requirement is not met as evidence by: Based on record review and staff interviews, the licensee did not comply with the section cited above by ensuring that injections are administered by an appropriately skilled professional. Records show that Medication Technicians (Med Techs), who are not appropriately skilled professionals, were administering insulin injections and performing blood glucose checks for R2. S1 confirmed that Med Techs “set up” insulin pens and used a “hand-over-hand” method during injection. This failure to ensure proper training and delegation in medication administration poses a potential health and safety risk to residents, including risk of injury, infection, or medication error.
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87622(a)(2)Type B
Fecal Impaction Removal, Enemas, and/or Suppositories(a) The licensee shall be permitted to accept or retain a resident who requires manual fecal impaction removal, enemas, or use of suppositories under the following circumstances: (2) Manual fecal impaction removal, enemas, and/or suppositories shall be permitted if administered according to physician's orders by either the resident or an appropriately skilled professional.This requirement was not met as evidenced by: Based on record review and interviews, the licensee did not comply with section above by not following dr's orders with R1 self-administering their intravaginal cream or appropriately skilled professional will administer the medication which poses a potential health and safety risk to the persons in care.

FAQ · About this visit

Common questions about this visit

What happened during the December 9, 2025 inspection of KENSINGTON AT WALNUT CREEK, THE?

This was a complaint inspection of KENSINGTON AT WALNUT CREEK, THE on December 9, 2025. 2 citations were issued: 2 Type B.

Were any citations issued to KENSINGTON AT WALNUT CREEK, THE on December 9, 2025?

Yes, 2 citations were issued (0 Type A, 2 Type B). The first citation was for: "CCR 87465 Incidental Medical and Dental Care(g) The licensee shall immediately telephone 9-1-1 if an injury or other cir..."

What type of inspection was this?

This was a complaint inspection. Complaint inspections are triggered when someone reports a concern about the facility to CCLD.

SourceView on CCLD View original report

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Data from CCLD public records. Last updated May 25, 2026. If you believe any information is inaccurate, report it here.

complaint·December 9, 2025