Kensington Place Redwood City

We haven’t transcribed this report yet. The complete document is on the state’s site.

Type of visit: Case Management - Incident

On 8/5/2026, LPA Grace Donato conducted an unannounced Case Management - Incident visit. LPA met with Director of Nursing (DON), Carol Blackwell and explained the purpose of the visit. On 7/30/26 at around 10:30am, facility became aware of an alleged resident (R1) abuse incident involving a Hospice Aid while providing personal care to the resident who became resistive prior to receiving shower. Witnesses reported that the aid handled the resident roughly, placed hand to the R1s mouth & continued the shower despite the nurse's instruction to stop the care & allow time for the R1s medications to take effect. Facility staff immediately reported what they had witnessed to LVN on shift. LPA spoke with DON, Facility has a practice of having a facility staff help with any hospice resident when hospice staff are around. DON did all the cross reports necessary. R1 did not sustain any injury during the shower. Hospice facility has provided a new hospice aid for R1. LPA collected documents from the facility. No citations issued today. Report is reviewed and copy is provided.the state’s words, verbatim · CDSS document, Aug 5, 2026

Allegation investigated: Staff did not ensure resident received one-to-one care staff

On 7/16/2026, Licensing Program Analyst(LPA) John Calandra arrived at the facility to deliver conclusionary findings for this complaint received by the Department on 4/28/2026. LPA Calandra was greeted by April Vargas, Executive Director and explained the purpose of the visit. Complainant alleged that R1 was supposed to receiving one to one care from S1 but was not. Based on interviews and record review, R1 did not have a 1:1 agreement and was receiving companion services from S1 not assistance with activities of daily living(ADLs). In addition, S1 was providing companion services after their shift had ended and on occasions when they were sick or on vacation notified the responsible party/power of attorney(poa) they would not be able to work. Based on record review and interviews conducted, R1 was not receiving one to care from S1. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the above allegation is UNSUBSTANTIATED at this time. An exit interview was conducted and a copy of the report was provided to the facility representative. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 16, 2026 · control 14-AS-20260428091442

Type of visit: Case Management - Other

On 11/4/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit in regards to an immediate exclusion of S1. LPA Calandra met with April Vargas, Executive Director and Iris Pierce, Associate Executive Director and explained the purpose of the visit. According to the Administrator, April Vargas, S1 has not been working at the facility since 7/29/2025, and will not return to work as of 11/4/2025. LPA received a copy of the termination letter for S1. No deficiencies cited during today's visit. An exit was conducted. This report was reviewed with facility representatives and a copy of the report provided.the state’s words, verbatim · CDSS document, Nov 4, 2025

Type of visit: POC

On 10/23/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to complete the Proof of Correction(POC) visit in regards to the deficiency on 10/22/2025. LPA Calandra was greeted by April Vargas, Executive Director. On 10/22/2025, the Licensee was cited for California Code of Regulations(CCR) 87465(h)(5) Incidental Medical and Dental Services as the Licensee did not ensure that resident's medications were stored in its' originally received container. On 10/23/2025, LPA verified that all resident's medications were stored in their originally received container. The deficiency was cleared during the visit. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with facility representative and a copy provided.the state’s words, verbatim · CDSS document, Oct 23, 2025

Type of visit: Case Management - Annual Continuation

On 10/22/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to continue the 1-year required Annual inspection. LPA Calandra was greeted by Carol Blackwell, Director of Nursing Services and explained the purpose of the visit. April Vargas, Executive Director arrived later during the visit. LPA inspected the facility's first aid kits. Each kit had a current edition of a first aid manual, sterile first aid dressings, bandages, scissors, tweezers, and a thermometer. LPA received a copy of the current LIC 500. A review of Centrally Stored Medications indicated that medications for residents were properly labeled with instructions on dosage and times of day and matched the Centrally Stored Medication Records(CSMR) kept at the facility. During the visit, LPA observed pills in the medication cart that were not stored in their original container. In the presence of the LPA, Director of Nursing, Carol Blackwell placed the medications in a plastic cup and secured them. Deficiencies are cited under the California Code of Regulations, Title 22. Failure to correct the deficiencies by the due date may result in civil penalties. An exit interview was conducted. This report was reviewed with facility representative and a copy of the report provided along with appeal rights.the state’s words, verbatim · CDSS document, Oct 22, 2025

Type of visit: Case Management - Annual Continuation

On 10/16/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to continue the Annual 1-year required inspection. LPA Calandra was greeted by April Vargas, Executive Director and explained the purpose of the visit. LPA toured the physical plant, This is a 2-story building with 39 bedrooms and bathrooms, a parlor, cafe, kitchen, activity room, staff lounge, lobby, laundry. All bedrooms had the required furniture and sufficient lighting. All bathrooms had the required grab bars and anti-skid floor mats. All smoke alarms and carbon monoxide detectors were observed to be in working order. Per interview with Danilo Barbieri, Director of Environmental Services the facility's fire alarms and Carbon Monoxide detectors are connected directly to the Redwood City Fire Department. No accessible bodies of water or hazards were observed in the outdoor area. The facility had the required 7 days of non perishables and 2 days of perishables on hand. No food was expired. All sharp objects, soap, detergents, and poisons were observed to be locked and in-accessible to persons in care. LPA reviewed 6 staff files. All were observed to be complete. No deficiencies were cited during today's visit. The Annual inspection will be completed at a later date. An exit interview was conducted. This report was reviewed with facility representative and a copy of the report was emailed.the state’s words, verbatim · CDSS document, Oct 16, 2025

Type of visit: Required - 1 Year

On 10/1/2015, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct the 1-year required Annual Inspection. LPA Calandra was greeted by CC DeGraff, Senior Executive Director and April Vargas, Executive Director/Administrator and explained the purpose of the visit. LPA Calandra reviewed 10 resident files. All were observed to be complete. The Annual inspection will be completed at a later date. No deficiencies were cited during today's visit. An exit interview was conducted. A copy of this report was emailed to the facility representatives.the state’s words, verbatim · CDSS document, Oct 1, 2025

Allegation investigated: Facility staff did not provide a refund to resident's responsible person

On 9/4/2025, Licensing Program Analyst(LPA) John Calandra met with facility representative for this conclusionary complaint investigation. LPA Calandra explained the purpose of the visit. Complaint alleged that the facility did not provide a refund to resident’s responsible party. Based on document review and interviews, S1 sent R1’s responsible party a refund check which could not be deposited due to a printing error. Thus, S1 sent a subsequent refund check to resident’s responsible party which they were able to deposit. Based on the fact that the resident’s responsible party was refunded the allegation is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur. Therefore the above allegation is unsubstantiated at this time. Nothe state’s words, verbatim · CDSS document, Sep 4, 2025 · control 14-AS-20250620155832

Type of visit: Case Management - Other

On 6/4/2025, Licensing Program Analyst(LPA) John Calandra arrived at the facility to conduct a Case Management visit for the purpose of delivering a letter of immediate exclusion for S1. LPA Calandra was greeted by Karen Nickolai, Executive Director and explained the purpose of the visit. Laura Avalos, Manager of Team Member Services and Human Resources arrived later during the visit. According to Ms. Avalos, S1's last day of work was 03/7/2025. No deficiencies cited during today's visit. An exit interview was conducted. This report was reviewed with facility representative and a copy of the report along with the immediate exclusion letter left at the facility.the state’s words, verbatim · CDSS document, Jun 4, 2025

Allegation investigated: Facility is not providing updates regarding R1s care needs to responsible party. Facility is not meeting R1s care needs in regard to ADLs.

On 3/12/2025, Licensing Program Analyst (LPA) John Calandra met with Carol Blackwell, Director of Nursing for this conclusionary complaint inspection. On 2/6/2025, LPA conducted initial complaint inspection and conducted interviews and reviewed resident records. LPA later gathered more information regarding the above allegations regarding possible personal rights and level of care violations. The resident (R1) in this complaint no longer resides at the facility and has been unable to be interviewed and no further information has been able to be obtained by complainant. Based on information gathered from facility and review of resident records and interviews conducted, it was determined facility conducted the required resident appraisal upon admission to facility. LPA checked and reviewed subsequent resident reappraisals, and it was found that the care needs of R1 were being met until an incident occurred in which R1 displayed a change of behavior, however facility was unable to do a follow up appraisal because R1 had not returned to the facility after responsible party removed Unsubstantiated resident from facility. Since facility could not reappraise R1 after an incident, it is unknown the level of care that may have been needed. Based on the Department's investigation, it was determined there was a lack of sufficient evidence to support or deny the allegations. Based on this information, the findings of these allegations are unsubstantiated. This report was reviewed and discussed with facility representative and a copy of this report must be made available for public review upon request.the state’s words, verbatim · CDSS document, Mar 12, 2025 · control 14-AS-20250130121349

Type of visit: Case Management - Incident

On 12/27/2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 8:30 AM to conduct a Case Management visit for the purpose of following up on a self-reported incident and met with Jessi Kaur, Memory Care Director and Alberto Golia, Executive Director. LPA was informed that on 12/19/2024, R1 had wandered out of the facility unassisted. R1 was found several minutes after staff were aware of their absence and located R1 approximately 1 block away with no signs of injury or change of condition. Upon file review, R1 is not able to the facility unassisted. The facility is aware of R1's wandering behavior and did an elopement drills with all staff on all shifts on 12/19/2024. Furthermore, the facility has taken additional steps to ensure more individualized activities to keep R1 engaged. LPA found that facility is taking appropriate preventative measures to ensure R1 is provided individualized updates on supervision. Lastly, the facility is ensuring all residents are properly supervised and engaged moving forward. Deficiency cited from the California Code of Regulations, Title 22, Division 6 of California Regulation. Failure to correct the deficiency and/or repeat deficiencies within a 12-month period may result in civil penalties. An exit interview was conducted. This report was reviewed with Alberto Golia, Executive Director and a copy of the report along with Appeal Rights left at the facility.the state’s words, verbatim · CDSS document, Dec 27, 2024

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87411(a) · Plan of correction due date: Jan 10, 2025

87411 a) Personnel Requirements: Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. This requirement is not met as evidenced by: Based on record review and interview, the facility did not ensure that basic services such as care and supervision were being met which resulted in R1 AWOL. Furtheremore, the concierge has been transitioned to another department within the facility. This serves as a potential health, safety, or personal rights risk to persons in care.the state’s words, verbatim · CDSS document, Dec 27, 2024

Plan of correction: Facility has implemented additional precautionary measures including conducting additional staff elopement training and implemented personnel changes. LPA found that the facility has take appropriate measures for plan of corrections. Deficiency cleared at the time of visit.

Type of visit: Required - 1 Year

On October 9, 2024, Licensing Program Analyst(LPA) John Calandra arrived at the facility at 9:01 AM to conduct the unannounced 1-year Annual Inspection. LPA Calandra was greeted by Jassi Kaur, Director of Memory Care, and Rita Malhotra, Clinical Support Specialist and explained the purpose of the visit. Alberto Golia, Executive Director arrived later during the visit. LPA toured the physical plant, This is a 2-story building with 39 bedrooms and bathrooms, a parlor, cafe, kitchen, activity room, staff lounge, lobby, laundry. All bedrooms had the required furniture and sufficient lighting. All bathrooms had the required grab bars and anti-skid floor mats. All smoke alarms and carbon monoxide detectors were observed to be in working order. Per interview with Danilo Barbieri, Director of Environmental Services the facility's fire alarms and Carbon Monoxide detectors are connected directly to the Redwood City Fire Department. No accessible bodies of water or hazards were observed in the outdoor area. All sharp objects, poisons, detergents, and soap were locked and in-accessible to persons in care. LPA Calandra reviewed 5 staff files and 10 resident files. All were observed to be complete. LPA reviewed resident medications which matched the Centrally Stored Medication Records(CSMR) kept at the facility LPA received a copy of the facility's current Liability Insurance during the visit. No deficiencies were cited during today's visit. An exit interview was conducted. This report was reviewed with Alberto Golia, Executive Director, Rita Malhotra, Clinical Support Specialist and Carol Blackwell, RN/Director of Nursing.the state’s words, verbatim · CDSS document, Oct 9, 2024

Allegation investigated: - Staff did not ensure resident received their mail in a timely manner

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegation received. LPA met with Douglas Blake, soon to be administrator, and explained the purpose of today's visit. During the investigation LPA conducted interviews and made facility observations. It was discovered that the facility explains to responsible parties during the admission process that dementia resident mail is to be picked up from a centralized mail filing cabinet that holds resident mail. Bills and other important medical items are primarily housed in the mail filing cabinet. Due to no further information being received from incoming complainant this allegation is unsubstantiated. Based on these observations, the above allegations are UNSUBSTANTIATED. Although the allegations may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the above allegations are unsubstantiated at this time. Unsubstantiatedthe state’s words, verbatim · CDSS document, Dec 5, 2023 · control 14-AS-20230613102340

The state marks this report as 3 pages; the online copy we transcribed has 1. You can request the full file from the county licensing office.

Allegation investigated: - Facility did not have a call system in place and as a result resident was left on the floor for an extended period of time - Staff did not provide a care plan for resident

On this day Licensing Program Analyst (LPA) Jaime Vado conducted an unannounced complaint investigation visit to deliver the findings regarding the allegation received. LPA met with Douglas Blake, soon to be administrator, and explained the purpose of today's visit. During the investigation LPA conducted interviews, reviewed pertinent documents, and made facility observations. It is discovered that the facility does not have a pendant system in place but rather pull cords installed in resident rooms. Per observations there is a call system in place. The facility does have a pendant system in place as well and it is provided to residents that are able to use it on their own and based on their assessments. At the time the resident in this complaint resided in the facility they was not able to manage the pendant. The facility did provide one to the resident at the request of the responsible party but it was not utilized and it would often be found not on the resident due to behavior of removing the pendant and at times would throw it or lose it. Regarding not providing a care plan for resident, LPA received the care plan for the resident that was developed and updated through out the time the resident was in the facility and was provided to the responsible party. These allegations are unfounded. This agency has investigated the above complaints. We have found that the complaint was unfounded, meaning that the allegation was false, could not have happened and/or is without a reasonable basis. We have therefore dismissed the complaint. Report is reviewed with Douglas Blake. Unfoundedthe state’s words, verbatim · CDSS document, Dec 5, 2023 · control 14-AS-20230518124015