Inspection Reports for
The Kensington

The visit was triggered by a complaint involving an incident report about duplicate narcotic medication administration to a resident. The complaint was substantiated by record review and interviews.

The facility was found to have administered duplicate doses of a narcotic medication to a resident, contrary to physician orders, posing a potential health and safety risk. A Type B deficiency was cited for failure to administer medication according to physician directions.

The visit was complaint-related, triggered by multiple medication-related incident reports received by the Community Care Licensing Division on 12/09/2025, 11/20/2025, 10/20/2025, and 07/03/2025. The complaints involved medication errors such as wrong medication administration, missed medications, and medication given to a guest.

The inspection found multiple medication administration errors involving several residents, including wrong medication given, missed medications, and medication given inappropriately. Deficiencies were cited under California Code of Regulations, Title 22, posing potential health and safety risks.

The complaint investigation was substantiated. Allegations included staff mismanaging medications, falsifying medication records, and improper training of staff administering medications. The investigation included interviews, record reviews, and observations confirming these issues.

The investigation substantiated all allegations, finding that staff missed medication doses, falsified medication administration records, and that Medication Technicians administered insulin injections and performed blood glucose checks without appropriate training, posing potential health and safety risks to residents.

The visit was triggered by a complaint investigation (#15-AS-20241029121159) conducted on 10/16/2025. The complaint was substantiated by findings that medication technicians administered medication that should have been self-administered or administered by a skilled professional.

The facility was found to have allowed medication technicians to administer an intravaginal medication to a resident who was unable to self-administer medications, contrary to physician orders and applicable regulations. This noncompliance poses a potential health and safety risk.

The complaint investigation (#15-AS-20241029121159) was triggered by an incident where Resident 1 fell on or about 07/01/2024, was assisted by a witness, but emergency services were not called. The resident was found unresponsive and pronounced deceased on 07/02/2024. The investigation substantiated that emergency medical services were not activated following the fall.

The investigation found that the facility failed to activate emergency medical services following a resident's fall with head impact, and there was no documentation of ongoing monitoring or reassessment of the resident's condition. The resident was later found deceased with bruising noted. A Type B deficiency was cited for failure to immediately telephone 9-1-1 in an apparent life-threatening medical crisis.

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 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 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 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 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.

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 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.

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 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.

Complaint investigation #15-AS-20241029121159 was conducted. The deficiency was substantiated as two staff were not fingerprinted. The administrator agreed to correct the deficiency by the plan of correction due date.

Two staff members (S2 and S5) were found not fingerprinted and associated with the facility, violating Title 22 California Code of Regulations. The administrator agreed to have them fingerprinted and submit documentation by the plan of correction due date.

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

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.

The visit was triggered by a complaint regarding a resident eloping from the Memory Care unit. The complaint was substantiated by observations and interviews confirming the resident left the facility due to malfunctioning egress doors and insufficient staff supervision.

The facility failed to maintain properly functioning egress doors in the Memory Care unit, allowing a resident to elope, and did not have sufficient trained staff to meet care and supervision needs, posing an immediate health and safety risk.

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.

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

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 visit was complaint-related. The deficiency involved improper insulin administration by unqualified staff. Substantiation status is not explicitly stated.

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

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.

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.

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 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.

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 visit was triggered by a complaint regarding a medication error where a staff member gave the wrong medication to a resident during training. The complaint was substantiated as deficiencies were cited and corrective actions were taken.

The incident involved a staff member giving another resident's medication to a resident in error. The facility notified the resident's physician and family, placed the resident on 72 hours monitoring, and provided additional training to the staff involved. A deficiency was cited related to residents' personal rights, which was cleared after an in-service training was conducted.

The visit was triggered by an Unusual Incident Report regarding a resident who exited the memory care unit through an unsecured window. The complaint was substantiated by observations and interviews.

The licensee failed to secure the windows and window screens in the memory care unit, allowing a resident to force open a window and exit, posing an immediate health and safety risk. The facility installed window stoppers and sensors as corrective measures.

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 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 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 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.