Inspection Reports for The Kensington

The visit was an unannounced case management inspection conducted in response to incident reports received by the Community Care Licensing Division on 01/02/2025, concerning late reporting of unusual incidents occurring between November and December 2024.

The inspection found deficiencies related to failure to submit written incident reports within the required seven-day timeframe, posing a potential risk to the health, safety, or personal rights of persons in care. Deficiencies were cited under California Code of Regulation, Title 22.

The visit was triggered by complaint-related incident reports (Unusual Incident Reports) received late by the licensing agency, with substantiation implied by the citation of deficiencies.

The visit was an unannounced case management inspection conducted in response to incident reports received regarding a resident's elopement incidents on 06/16/2025 and 06/18/2025.

The inspection found that the facility failed to report the resident's elopement within the required timeframe, posing a potential risk to health, safety, or personal rights. The resident was noted to have dementia and was not able to leave the facility unassisted. A plan of correction was issued with a due date of 09/03/2025.

The visit was triggered by two Unusual Incident Reports received on 06/23/2025 regarding resident R1 leaving the community unassisted on 06/16/2025 and 06/18/2025. The resident's Wander Guard did not activate on the first incident but did on the second. The family started a 1:1 companion on 06/18/2025 following these incidents. The resident has a diagnosis of dementia and is not able to leave unassisted.

The visit was an unannounced case management inspection conducted in response to incident reports received regarding a medication error that occurred on 12/01/2024.

The inspection found that the facility did not comply with medication administration requirements, specifically failing to administer medication for resident R1 according to the physician's directions, posing a potential health and safety risk. Deficiencies were cited under California Code of Regulation, Title 22.

The visit was triggered by a complaint involving an unusual incident report received on 01/02/2025 concerning a medication error on 12/01/2024 where R1 was assisted with the wrong medication by a Med Tech. The Med Tech no longer works at the facility. The complaint was investigated during the visit.

An unannounced complaint investigation was conducted in response to an allegation of unlawful eviction received on 2025-08-22.

The investigation substantiated the allegation that the eviction notice given to a resident did not include the correct contact information for the local ombudsman, violating California Code of Regulations. The facility did not rescind the eviction notice promptly but was working on a revision and notified the resident's responsible party.

The complaint investigation was substantiated. The allegation of unlawful eviction was confirmed based on interviews and document reviews. The eviction notice lacked appropriate ombudsman contact information and was not rescinded timely.

An unannounced complaint investigation was conducted in response to an allegation that staff does not ensure the facility is free of pests.

The investigation found no preponderance of evidence to substantiate the allegation. Interviews with staff and review of exterminator service records showed ongoing pest control measures, and no pests were observed during the visit.

The complaint alleging that staff does not ensure the facility is free of pests was unsubstantiated after investigation.

The inspection was an unannounced 1-Year Annual Required inspection conducted to evaluate compliance with licensing requirements.

The inspection found multiple deficiencies including unsafe hot water temperatures exceeding regulatory limits, unsecured prescription medications accessible to a resident, incomplete staff training records, and missing required postings. Plans of correction were requested with specific due dates.

The visit was an unannounced case management inspection conducted during a complaint investigation (#15-AS-20241029121159) to review compliance with fingerprinting requirements for staff.

Two staff members (S2 and S5) were found not fingerprinted and associated with the facility, violating Title 22 California Code of Regulations, posing a potential health and safety risk to persons in care.

Complaint investigation #15-AS-20241029121159 was conducted. The deficiency was substantiated based on observation and record review.

An unannounced Case Management visit was conducted regarding an Unusual Incident Report (UIR) about a resident (R1) eloping from the Memory Care unit on 10/19/2024.

The facility failed to maintain egress doors properly and did not have sufficient trained staff to prevent resident elopement, posing an immediate health and safety risk. Two Type B deficiencies were cited related to maintenance and staff supervision.

The visit was triggered by a complaint regarding a resident eloping from the Memory Care unit on 10/19/2024. The complaint was substantiated by observations and interviews confirming the incident and deficiencies.

Unannounced Case Management - Deficiency visit to review the status of previously cited deficiencies from an Annual Inspection conducted on 2024-08-07 and to evaluate the Plan of Correction submissions.

The facility had not cleared two deficiencies related to annual medical assessments for residents with dementia and required staff annual training. The Plan of Correction submissions were incomplete, and the facility requested additional time to complete staff training by the end of the year.

The inspection was an unannounced Required - 1 Year annual inspection conducted to evaluate compliance with licensing regulations and facility standards.

The inspection identified multiple deficiencies including missing current medical assessments for residents, lack of TB tests, incomplete health screenings and annual training for staff, and failure to conduct quarterly disaster drills. Plans of correction were agreed upon to address these issues by 08/30/2024.

An unannounced Case Management inspection was conducted as part of a complaint investigation to assess compliance with regulations regarding medication administration.

A deficiency was found where a non-skilled staff member administered insulin to a resident who was unable to self-administer injections, violating California Code of Regulation, Title 22.

The visit was complaint-related and substantiated by the observation that a non-skilled staff member administered insulin to a resident unable to self-inject, posing a health and safety risk.

The inspection was an unannounced complaint investigation conducted in response to allegations received on 2024-01-09 regarding staff mismanagement of residents' medication and inaccurate medication logs.

The investigation substantiated the allegation that staff mismanaged residents' medication, including failure to administer insulin Lispro injections as prescribed, posing a potential health and safety risk. The allegation regarding inaccurate medication logs was unsubstantiated as records were found to be complete and accurate.

The complaint investigation was substantiated for staff mismanagement of residents' medication, specifically failure to administer insulin Lispro injections for multiple days without documentation. The allegation that staff did not keep an accurate medication log was unsubstantiated.

An unannounced Case Management visit was conducted regarding an Unusual Incident Report (UIR) about suspected elder abuse reported on 2024-01-27.

The investigation found allegations that a caregiver threatened a resident with harm. The caregiver was placed on paid administrative leave and subsequently terminated. No deficiencies were issued during the visit.

The complaint involved suspected elder abuse where a caregiver allegedly told a resident that if she fell, she would be sent to the hospital and have her leg cut off. The caregiver was terminated following the investigation.

An unannounced Case Management visit was conducted regarding an Unusual Incident Report (UIR) reported on 03/03/2024 involving a medication error during staff training.

The incident involved a staff member giving another resident's medication to a resident in error. The care staff notified the resident's physician and family, and the resident was placed on 72 hours monitoring. Additional training was provided to the staff member on the same day. Deficiencies were cited related to residents' personal rights and competency to meet their needs.

The visit was complaint-related due to an Unusual Incident Report involving a medication error. The report indicated the error was addressed with notification to physician and family, monitoring of the resident, and additional staff training.

The visit was an unannounced Case Management inspection regarding an incident of Suspected Elder Abuse reported to the Community Care Licensing Division from Adult Protective Services.

The investigation substantiated that a caregiver yelled at a resident in memory care and used threatening language, resulting in the caregiver's termination. No deficiencies were issued during the visit.

The complaint involved an incident on 01/23/2024 where a caregiver yelled at a resident to be quiet and threatened a cold shower, also roughly placing the resident's walker in front of them. The allegation was substantiated after corroboration from other caregivers and witnesses. The caregiver was placed on paid administrative leave and subsequently terminated on 02/02/2024.

An unannounced Case Management visit was conducted regarding an Unusual Incident Report filed on 01/31/2024 about a memory care resident (R1) who was seen entering the community through the front lobby at around 10:30 PM, with concerns about unsecured windows and window screens.

The licensee failed to secure the windows and window screens in memory care, posing an immediate health and safety risk to residents. The resident was able to force open a window and remove the screen, which was confirmed by observation and interview.

The visit was complaint-related based on an Unusual Incident Report regarding a resident leaving memory care unsupervised. The complaint was substantiated by observations and interviews confirming the resident could force open windows and remove screens.

The visit was an unannounced Case Management visit to follow-up on a death report received by Community Care Licensing regarding a resident's death.

No deficiencies were cited during this visit. The Licensing Program Analyst obtained additional information related to the resident's death and requested a copy of the death certificate and police report.

An unannounced pre-licensing inspection was conducted because the facility is in operation and changing ownership.

The inspection found no issues; the facility was inspected inside and out, including apartments, common areas, and safety features. The facility is ready to be licensed, subject to final approval by the Central Applications Unit.

The inspection was conducted as a Component III Review for the Pre-licensing Inspection of the facility.

Licensing Program Analysts presented a Component III power point and discussed regulations with the Interim Executive Director, who demonstrated knowledge about running and maintaining the facility in accordance with regulations. An exit interview was conducted and a copy of the report was provided.

The visit was conducted as part of the Component II completion for a Change in Ownership (CHOW) application for a Residential Care Facility for Elderly (RCFE).

The Component II completion was successful, confirming that the Applicant and Administrator understand community care facility licensing laws and regulations, including facility operation, admission policies, staffing, health conditions, general provisions, emergency preparedness, complaints and reporting, and pre-licensing readiness.