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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 02/17/2026 at 10:15 AM, Licensing Program Analyst (LPA) L. Alexander arrived unannounced to conduct a case management visit regarding incident reports received by the Community Care Licensing Division (CCLD) on 01/07/2026. LPA met with Assistant Executive Director Deborah Bradley and Executive Director Specialist Kelly Reynolds and explained the purpose of the visit. LPA received an Unusual Incident Report (UIR) regarding an incident that occurred on 01/03/2026 indicating that Staff (S1) administered a narcotic medication dose to Resident (R1) at approximately 7:49 AM and administered another dose of the same narcotic medication at 8:36 AM. LPA reviewed R1’s physician’s orders, Medication Administration Record (MAR) for January 2026, and narcotic log. Documentation indicates the medication hydrocodone/APAP 5/325 mg tablet was ordered to be administered as one tablet twice daily, every four hours. The UIR indicated R1 refused the evening dose. The UIR further documented that on 01/04/2026, Staff (S2) notified Staff (S3) that R1 had been administered two doses of the medication that morning. Administrative review identified duplicate medication orders within the facility’s QMAR system. LIC809-C Continued... LIC809-C (Page 2) LPA obtained copies of R1’s physician’s report, care plan dated 12/01/2025, MARs for January through February 2026, Resident Roster, Staff Roster (LIC 500), Med Tech roster, and Med Tech training transcripts for fourteen (14) Med Tech staff and Med Tech schedules (Dec '25 thru Feb '26). Based on record review, deficiencies were observed and cited in accordance with the California Code of Regulations, Title 22 (see LIC 809D). Failure to correct the deficiencies may result in civil penalties. An exit interview was conducted, and a copy of this report and appeal rights were provided to facility representatives.

Citations

1 citation 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(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. R1 was administered the same dose of narcotic medication in the morning 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 February 17, 2026 inspection of KENSINGTON AT WALNUT CREEK, THE?

This was a other inspection of KENSINGTON AT WALNUT CREEK, THE on February 17, 2026. 1 citation were issued: 1 Type B.

Were any citations issued to KENSINGTON AT WALNUT CREEK, THE on February 17, 2026?

Yes, 1 citation was issued (0 Type A, 1 Type B). The first citation was for: "87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing... facility staff designa..."

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