Kentfield Estates Ranch RCFE

Type of visit: Annual/Random

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/1/26 to conduct a Annual Inspection . In a department computer program switch, Annual Required inspection nor the CARE tool are available. Administrator is present to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. LPA and Admin discussed pending repairs to the rear decking. LPA reviewed 3 resident files. Files are complete.LPA and Admin discussed organizing of files. LPA and Admin also discussed more detail to behavior expressions plans when behaviors are identified in resident files. LPA reviewed 2 staff files. Files are complete. LPA and Admin discussed adding restricted health conditions to training records for training to be done when residents with a condition is present in care. LPA requested the following documents to update the facility file: Current Liability ins. cert. No deficiencies are being cited as a result of todays inspection. Exit interview conducted with licensee and copy of report left at the facility.the state’s words, verbatim · CDSS document, Sep 1, 2026

Allegation investigated: Facility staff did not administer medications as prescribed.

On 4/29/26, Licensing Program Analyst (LPA) Kevin Mknelly spoke with caregiver S1 to deliver complaint findings for the above allegation. LPA spoke with Admin by phone but Admin was not available to attend. LPA reviewed resident records, facility and conducted interviews. LPA finds that the allegations cited above are substantiated. Based on medication records review Nov 2024- Dec 2025, and staff interviews it was found that there were many irregularities in medication administration records (MARs) and medications ordered as as needed were administred daily without required PRN record of medication, reason needed and result of the medication. There were also gaps in medication when refills were late. Statements indicated that refills were ordered but family delivery was not always reliable. The system were changed to pharmacy delivery. report continued... Substantiated As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with designee . Copy of this report and appeal rights provided. Therefore, there was not sufficient evidence to conclude that a lack of care and supervision lead to the hospitalization. As a result of this investigation, LPA finds allegation to be (US)Unsubstantiated - A finding that the complaint is Unsubstantiated means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. Exit interview with designee..the state’s words, verbatim · CDSS document, Apr 29, 2026 · control 59-AS-20260313115040

From the deficiency page — Deficiency type: Type B · Section cited: CCR 87465 · Plan of correction due date: May 27, 2026

Incidental Medical and Dental Care (a)(4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met based on records and interview statements. This posed a potential risk to the resident.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Licensee will submit a statement of procedures for med intakes, physicians orders on file, documentation of PRNs administered and notification to MD or missed or refused medications. This procedure will be reviewed with all staff and verified by signatures by the POC date of 5/27/26

Type of visit: Case Management - Deficiencies

On 4/29/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver/ designee. On 3/17/26, while LPA was conducting a complaint investigation, it was found that S1 is working without a completed background check. S1 had been employed and working at the facility for some time. Though a live scan requests had been submitted prior to employment, the Admin did not verify the clearance before allowing S1 to work. S1 moved from the home/ work and completed a new clearance check. S1 was cleared and has returned to work. As a result of this inspection, the following deficiencies were cited on 809-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Apr 29, 2026

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87355 · Plan of correction due date: Apr 30, 2026

Criminal Record Clearance- (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:...(2) Obtain a California clearance or a criminal record exemption as required by the Department This requirement was not met based on records. This posed an immediate risk to residents.the state’s words, verbatim · CDSS document, Apr 29, 2026

Plan of correction: Licensee had removed S1 from presence in the home until a clearance was returned. This POC is cleared by this visit. Civil Penalties applied.

Type of visit: Case Management - Other

On 3/10/26, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit and met with a caregiver/ designee. LPA spoke with the Administrator regarding the visit. On 8/28/25, LPA conducted an annual inspection in which several topics were discussed and LPA issued advisories. This inspection is to follow-up on agreed to actions. Administrator was to submit plans for individual and group activities for current residents and a spot and deep cleaning plan for the common areas and resident rooms of the home. The plans were not received and still are to be submitted. In today's inspection, cleaning was better. However, staff interviewed did not have a clear plan for daily, weekly and monthly cleaning/ disinfecting tasks. LPA observed hallway door, hallway walls and bathroom door to need cleaning and possibly repainting. LPA also noted cooking oil buildup around the stove and some freezer damaged food in freezers. Licensee will also submit statements of resolution of these issues. As a result of today’s inspection, no deficiencies were noted. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Mar 10, 2026

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 8/28/25 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator arrived to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. Residents appear to have their care needs met by two staff present. LPA reviewed 2 resident files. LPA reviewed 2 staff files. Several topics were discussed with the Administrator. Licensee will submit proof of liability insurance , plan for activities for current residents and a cleaning plan for the common areas of the home. As a result of this investigation no deficiencies are noted at this time. Report reviewed with administrator. Copy of this report provided.the state’s words, verbatim · CDSS document, Aug 28, 2025

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Kevin Mknelly arrived at the facility unannounced on 9/4/24 to conduct a Annual Inspection utilizing the CARE inspection tool. LPA met with staff and explained the purpose of the visit. LPA requested for staff to notify Administrator that LPA is present at the facility to conduct an annual inspection. Administrator was unavailable to assist. LPA toured the interior and exterior of the facility together with staff to ensure health and safety of residents in care. Areas toured include but are not limited to: common areas, resident bedrooms, bathroom, kitchen, laundry room, and backyard. In the areas toured no immediate health, safety, or personal rights violations were observed. The home is clean and residents appear to have their care needs met. LPA reviewed 6 resident files. R1 and R1 need hospice care plans and R5 and R6 need updated Needs and Services Plans LPA reviewed 2 staff files. S1 needs 1st aid training, S1 and S2 need training for restricted conditions present. S2's file is still being completed. Licensee will submit proof of liability insurance and Admin certificate. As a result of this investigation, LPA finds allegation to be (S) Substantiated - A finding that the complaint is Substantiated means that the allegation is valid because the preponderance of the evidence standard has been met. The following deficiencies were cited on 9099-D, per Title 22 Regulations, Division 6. (A)This poses an immediate Health and Safety risk to clients/residents in care. (B) This poses a potential Health and Safety risk, or personal rights violation, to clients/residents in care. Report reviewed with designee. Copy of this report and appeal rights provided.the state’s words, verbatim · CDSS document, Sep 4, 2024

The state marks this report as 9 pages; the online copy we transcribed has 2. You can request the full file from the county licensing office.

Type of visit: POC

On 2/15/24, Licensing Program Analyst (LPA) Kevin Mknelly conducted a plan of correction (POC) visit follow- up to citations issued 2/7/24. LPA informed the caregiver of the reason for the visit. Caregiver accompanied LPA to confirm all fire safety issues have been corrected and are currently operational. The plan of correction is cleared. No deficiencies are noted this visit. Report reviewed and copy provided to Lindiwe Musikavanhu.the state’s words, verbatim · CDSS document, Feb 15, 2024

Type of visit: Case Management - Other

On 2/7/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver. LPA spoke by phone with Administrator to review the findings of this visit. LPA was following up on issues noticed on 2/6/24. LPA advised the Administrator of the following issues to be remedied by 2/19/24: fire door to resident rooms hall- door stop may not be used and door lock must be removed; Smoke detector chirping- must have battery replaced; Rm 4 slider/ fire exit does not open- must be repaired; Back porch slider is hard to open- must be able to open easily; Porch to right ramp exit blocked with furniture- furniture was moved while LPA was present; Porch rail gate to the left pad locked- lock must be removed if that pathway is a designated exit route.. As a result of today’s inspection, deficiencies were noted. Report reviewed. Copy of report and appeal rights provided.the state’s words, verbatim · CDSS document, Feb 7, 2024

From the deficiency page — Deficiency type: Type A · Section cited: CCR 87203 · Plan of correction due date: Feb 9, 2024

87203 Fire Safety- All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement was not met based on observations. This poses an immediate risk to residents.the state’s words, verbatim · CDSS document, Feb 7, 2024

Plan of correction: Licensee will submit statement to CCL that the issues identified have been corrected by noon on 2/9/24. Deficiency to be cleared by visit.

Type of visit: Case Management - Other

On 2/6/24, Licensing Program Analyst (LPA) Kevin Mknelly, conducted a case management visit while delivering complaint findings and met with caregiver. Administrator was notified and arrived to assist. On 2/5/24, the department received a death report and phone contact from the administrator regarding the unexpected death of a resident. On 2/2/24 at approximately 6:30 AM, R1 had an unwitnessed fall from their wheelchair. Caregiver responded when they heard the fall. R1 was unresponsive. Caregiver initiated CPR and activated 9-1-1. R1 was unable to be revived. Records review showed R1 to have extensive chronic health issues. R1 had limited verbal communication ability yet was constantly observed and no health concerns were apparent in the previous 24 hours. LPA observed the location of the fall outside the bathroom and found no hazards. As a result of today’s inspection, no deficiencies were noted. LPA did advise that the door lock be removed from the fire door to resident rooms. Licensee will consider installing a fire door release magnet system. Report reviewed. Copy of report and appeal rights providedthe state’s words, verbatim · CDSS document, Feb 6, 2024