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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 12/09/2025 at 2:00 PM, Licensing Program Analysts (LPAs) L. Alexander and K. Nguyen arrived unannounced to conduct a case management visit. LPAs met with Executive Director (ED) Dolly Bindar and explained the purpose of the visit. During a complaint investigation (#15-AS-20241029121159) conducted on 10/16/2025, LPAs reviewed records and obtained witness statements related to an incident involving Resident (R1). On 10/13/2025, LPAs interviewed Witness (W2), who stated that on or about 07/01/2024, R1 attempted to sit in a chair, stumbled, and fell while Witness (W3) was on a FaceTime call with W2. W2 stated they received a call from W3 advising of the fall and drove to the facility. Upon entering R1’s apartment, W2 stated they observed R1 on the floor and assisted R1 back to a standing position. W2 reported remaining with R1 in the apartment while watching television. W2 stated that facility staff entered the apartment to assess R1; however, W2 advised staff that R1 was okay and stated that emergency services were not needed. W2 reported assisting R1 into bed and then leaving the facility. LIC809-C Continued... LIC809-C (Page 2) W2 further stated that on 07/02/2024, they returned to R1’s apartment in the morning and found R1 unresponsive. LPAs reviewed a Walnut Creek Police Department (WCPD) report, which indicated that on 07/02/2024, R1 was pronounced deceased at the facility. The report documented the presence of slight bruising to the right side of R1’s face and the right elbow. Facility records reviewed did not document that emergency medical services were contacted following the reported fall involving head impact, nor did records reflect ongoing monitoring or reassessment of R1’s condition following the incident. The deficiencies were observed (see LIC809D) and cited from the California Code of Regulation, Title 22. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of this report and appeal rights 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.

  • 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 other inspection of KENSINGTON AT WALNUT CREEK, THE on December 9, 2025. 1 citation were issued: 1 Type B.

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

Yes, 1 citation was issued (0 Type A, 1 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 other inspection. other inspections are conducted by CCLD as part of their licensing oversight.

SourceView on CCLDView original report

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