The Kensington Redondo Beach

Type of visit: Required - 1 Year

Licensing Program Analyst (LPA) Galarza conducted an unannounced Required- 1 year visit. LPA met with Director of Nursing Janie Acosta. Executive Director Robert May arrived shortly after. The Residential Care for Elderly (RCFE) facility serves residents ages 60 and over. The facility has two Memory Care Units for cognitively impaired residents. The following were observed/inspected: Infection Control: The Infection Control Plan was reviewed and is current. Operational Requirements: The facility has an approved fire clearance for 132 non-ambulatory residents, of which 30 may be bedridden. A hospice waiver for 30 residents is approved. Facility does not handle resident monies. Liability Insurance in the amount of at least ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate expires 6/1/2027. Physical Plant/Environment Safety: LPA toured the facility grounds. It is a two- story building consisting 91 resident rooms, lobby, library, cafe, loggia, kitchen, 4 dining rooms, parlor, piano lounge cafe, cinema, art studio, ocean room, family room, physical therapy room, massage room, doctor's office, 2 terraces, laundry room, medication room, and administrative offices. Twenty four (24) resident rooms, common areas were inspected. Resident rooms have required furniture, bedding, linens, mattress pads and lighting. Bathrooms are equipped with non-skid surfaces and grab bars. Exit doors are free of any obstruction. Cleaning supplies and toxic substances are inaccessible to residents. The signal system was tested and is operational. Water temperature readings measured within the required 105 - 120 degrees Fahrenheit. There are evacuation chairs on facility stairwells to be used during an emergency as a path of egress from the facility to safety. The facility is equipped with fire extinguishers, sprinklers, smoke detectors, and carbon monoxide detectors. The last fire inspection was conducted on 2/20/2026. Staffing: A total of 183 staff members provides care and supervision to the clients. Personnel Records/Staff Training: Administrator certificate expires 8/13/2026. 10 staff files were reviewed. They contained 1st Aid/CPR training, personnel records, health/TB screenings, and training records. Staff have criminal background clearance. Resident Records/Incident Reports: Ten (10) resident files were reviewed. They contained Admission Agreements, Service Plans, Physician's Reports, Appraisals, TB clearance, Physician's Orders, medical consent, and centrally stored medication records. RCFE & Ombudsman complaint posters are posted. Planned Activities: Facility activity calendar was posted. Sufficient space to accommodate both indoor and outdoor activities was observed. Food Service: Food supply was checked in the kitchen and pantry storage areas, consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Residents have physician orders for modified diets. A diet list was observed in the kitchen. Sanitation practices and kitchen cleanliness was observed. Executive Chef has current Food Manager Certification. The walk-in freezer had uncovered puree sweet potatoes and the head of a cabbage was spoiled. A citation was issued. Incident Medical and Dental: Centrally stored resident medications were reviewed; containing a 30-day supply of medications. Medical and dental transportation is provided by family or facility bus. Disaster Preparedness: Emergency and Disaster Plan LIC 610E was reviewed and is updated. Facility has a First Aid Kit and Manual. The last emergency disaster drill was conducted on 7/14/2026. Residents with Special Health Needs: There are currently 10 residents receiving hospice services and 10 residents receiving home health services. Individual Service Plans, Appraisals, and postural support physician orders are on file. Pursuant to Title 22 deficiencies a citation was issued. Exit interview was conducted with Robert May. A copy of report and appeal rights were issued.the state’s words, verbatim · CDSS document, Aug 10, 2026

Allegation investigated: Staff do not allow the residents to choose their own physician

On December 10, 2025, the Department conducted an initial visit to gather information regarding the allegation mentioned above. The Department met with Executive Director Robert May and explained the purpose of today's visit. LPA was granted entry to the facility. The investigation consisted of the following: • On December 10, 2025, the Department requested, reviewed, and obtained copies of the following documents: • Personnel Report (dated November 25, 2025) • Resident Roster (dated December 10, 2025) • Letter regarding Medical Director changes (dated November 6, 2025) Interviews were conducted with Staff Members #1 through #4 (S1–S4) as well as with Residents #1 through #6 (R1–R6). See continued LIC9099-C, page 2. Unsubstantiated Continued LIC9099-C page 2 Investigation revealed the following: Allegation: Staff do not allow residents to choose their own physician. On December 10, 2025, between 11:30 a.m. and 4:30 p.m., the Department conducted interviews with Staff #1 through #4 (S1–S4). S1–S4 stated that on November 6, 2025, a letter regarding the Medical Director changes was emailed to all residents’ families, responsible parties, Power of Attorney (POA), conservators, and a copy was provided to every resident in the facility. The letter was displayed at the front desk, with additional copies available for anyone to take. All four staff members (4 out of 4) confirmed that residents are allowed to choose their own physicians. Staff reported that residents had the option to retain their previous Medical Director or switch to the facility’s new Medical Director. All four staff members stated that residents who had been under the facility’s previous physician elected to switch for various reasons. Staff further states that the facility has never refused to allow any physician to enter. The Medical Director changes were documented in residents’ medical records, effective November 23, 2025. S1–S4 denied the allegation. On October 31, 2025, between 2:30 p.m. and 3:30 p.m., the Department interviewed Residents #1 through #6 (R1–R6). When asked whether staff forced residents to switch their physician to the facility’s new physician, all six residents (6 out of 6) stated they had options and were allowed to select their own physician. Residents confirmed they received a copy of the letter regarding the Medical Director changes, and that their families, responsible parties, Power of Attorney (POA), and conservators also received the letter. All six residents reported they had no concerns with the changes and agreed to them. Each resident (6 out of 6) confirmed they are satisfied with their current physician and denied the allegation. Based on interviews, available evidence, observation, information received, and records reviewed there was not enough sufficient evidence to support the allegations. 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 allegation is deemed unsubstantiated. There were no deficiencies cited. LPA Bunker provided Executive Director Robert May with copies of the LIC9099 and LIC9099-C Complaint Investigation Reports. An exit interview was conducted.the state’s words, verbatim · CDSS document, Dec 10, 2025 · control 11-AS-20251202145430

Allegation investigated: Facility staff are not properly reporting incidents. Facility staff are not ensuring resident receives podiatry care as needed.

On 12/02/25, Licensing Program Analyst (LPA) Regina Cloyd conducted a subsequent visit to gather information regarding the above allegation. LPA met with the Director of Nursing Janie Acosta and the purpose of the visit was explained. Investigation consisted of the following: On 10/24/2025, LPA obtained Personnel Report (dated 10/24/25), Register of Residents, eight resident Clinical View Reports (April 2025 – June 2025) and reviewed ten resident records. LPA interviewed Staff #1 – 12 and toured the Haven neighborhood. On 11/19/25, LPA interviewed Witness #1. On 12/01/25, LPA interviewed Witness 2 – 3, 5, 7. On 12/02/25, LPA interviewed Staff #1, #10, and #13. Note: LPA left a message for Witness #4, #6, #8, #9, and #10. Continue to LIC9099-C. Unsubstantiated Allegation: Facility staff are not properly reporting incidents Regarding the allegation, “facility staff are not properly reporting incidents,” it is being alleged that only two out six falls were reported for Resident #1. It is also alleged that the paperwork was not completed accurately since one fall resulted in an emergency room visit. Record review of clinical view report revealed R1 tripped (03/10/25) and fell (03/28/25; 04/12/25; 04/30/25). Responsible party/parties were notified on all four dates including the incident associated with the emergency room visit (04/12/25). Ten out of ten staff interviews (S2 - S3, S5 – S12) indicated that incidents are reported to the appropriate parties and are documented. Director of Nursing indicated families are contacted, the doctor is informed, and notes are made in the facility’s charting system. Witness #1, R1’s responsible party, indicated that the facility generally calls to report incidents. Four out four witness/responsible party interviews (W2 – W3, W5, W7) indicated that the facility staff report resident incidents. Regarding the allegation, “facility staff are not properly reporting incidents,” based on record review and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. Allegation: Facility staff are not ensuring resident receives podiatry care as needed. Regarding the allegation, “facility staff are not ensuring resident receives podiatry care as needed,” it is being alleged that Resident #1 has not received services since 02/24/25. It is alleged that R1’s Physician ordered daily foot care services on 05/16/25 and R1 has yet to receive services as of 10/14/25. Record review of Podiatrist encounter notes revealed R1 received services on 02/24/25, 05/04/25, and 10/10/25. Podiatrist Progress notes revealed R1’s nails were clipped on 09/04/25. Torrance Memorial (05/16/25) note revealed R1 is to receive daily foot care and podiatry evaluation every two months. Torrance Memorial (07/15/25) response note revealed R1’s feet is to be evaluated daily for sores, redness, dryness and to call with abnormal finding and provide nail clipping as needed. Eight out of eight staff interviews (S2, S5 – S7, S9-S12) indicated that residents receive podiatry services once every other month. Director of Nursing/S1 and S3 indicated that care partners do the daily care, notify the nurse, and will request a PRN or scheduled visit. S1 also indicated that R1’s August 2025 podiatry visit was pushed to 09/04/25 due to the Podiatrist’s schedule. S10 and S13 indicated they evaluate R1’s feet and look for redness, bumps, dryness, skin tears, and observe R1’s nail. S10 indicated that most reports are regarding nail length. Continue to LIC9099-C. Witness #1, R1’s Emergency Contact, indicated that the facility does have a podiatrist come but R1’s feet are not being cared for enough. W1 indicated that the Practitioner sent a note for daily foot care but W1 is not sure if R1 is receiving it. Four out four witness/responsible party interviews (W2 – W3, W5, W7) indicated that podiatry care is provided to residents. Regarding the allegation, “facility staff are not ensuring resident receives podiatry care as needed” based on record reviews and interviews, the Department found no evidence to support the allegation mentioned above. 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, as a result, the allegation is Unsubstantiated. No deficiencies were cited. An exit interview was conducted and a copy of this report was provided to the Director of Nursing Janie Acosta.the state’s words, verbatim · CDSS document, Dec 2, 2025 · control 11-AS-20251014093150

Type of visit: Required - 1 Year

On 08/01/2025, Licensing Program Analyst (LPA) Regina Cloyd and Antonine Richard conducted an unannounced required – annual inspection and met with Executive Director Robert May. The facility is licensed to serve 132 non-ambulatory residents, of which 30 may be bedridden. The facility has a hospice waiver approved for 30 residents and currently has 20 residents on hospice. The facility is a two-story building located in a residential neighborhood. It has three neighborhoods within the facility that includes: Assisted Living, Connections, and Haven. It consists of (116) bedrooms, (133) bathrooms, shaded courtyard, shaded front yard with water fountain, and trash area in the back of building in the south parking lot. Annual Fees are current. The first floor consists of Assisted Living, a kitchen, staff room, laundry room, dining room, library, four restrooms (three inside building and one outside courtyard area), lobby area, reception area, executive office, copy room, hallways, bistro, cinema room (team member desk), electric room, Continue to LIC809-C. Director of Team Support office, Maintenance closet, French dining room, Loggia with fireplace, dining supplies closet, and activity room. The second floor consists of the Connections and Haven neighborhoods. Connections consist of a closet with medical supplies, spa, linens storage, nursing supply storage, cafe, activity room, family room with fireplace and office, trash closet, electrical closet, toxic supplies closet, and patio. Haven consists of a cafe, activity room with sink, ocean room with balcony and fireplace, laundry room, trash closet, and electrical closet. Medication carts are in all three neighborhoods. The Connections Manager accompanied LPA Richard inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. All walkways, paths and passageways were clean, clear, and free of debris, hazards, and obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinets. The first Aid kit was available. Redondo Beach Fire Department completed the facility’s fire and safety inspection on 07/21/2025. It is approved for delayed egress and secured (locked) perimeter. Resident bedrooms (Rooms 109, 121, 213, 214, 221, 226, 229, and 237) had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Continue to LIC809-C. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 119.0°F (room 109) and 120.1°F (Room 237). Resident bath towels were adequately stocked. Common areas were clean and clear of hazards. Doorways were free of obstructions. Ten (10) staff records were reviewed, 10 out of 10 staff records had the required criminal record clearances or criminal record exemptions. Ten (10) resident records were reviewed, 10 out of 10 resident records had pre-appraisal or reappraisals. Four residents’ medication was reviewed. No deficiencies are being cited. An exit interview was conducted, technical assistance provided, and a copy of this report was discussed and left with the Associate Executive Director Rachael Martinez.the state’s words, verbatim · CDSS document, Aug 1, 2025

Type of visit: Required - 1 Year

On 07/27/24, Licensing Program Analyst (LPA) Regina Cloyd conducted an unannounced required – annual inspection and met with Executive Director Robert May. The facility is licensed to serve 132 non-ambulatory residents, all of which 30 may be bedridden. The facility has a hospice waiver approved 30 residents. The facility currently has 14 residents on hospice. Annual Fees are current. The facility is a two-story structure located in a residential neighborhood. The facility has three sections within the facility: Assisted Living, Connections, and Haven sections. It consists of 116 bedrooms, 133 bathrooms, shaded courtyard, shaded front yard with water fountain, and trash area in the back of building in the south parking lot. The first floor includes a kitchen, staff room, laundry room, dining room, library, four restrooms (three inside the building and one outside in the courtyard area), lobby area, reception area, executive office, copy room, hallways, bistro, cinema room (team member desk), electric room, Director of Team Support office, Maintenance closet, French dining room, courtyard with fireplace, dining supplies closet, and activity room. The second floor includes Connections and Haven sections. The Connections has a closet with medical supplies, spa, linens storage, nursing supply storage, cafe, activity room, family room with fireplace and office, trash closet, electrical closet, toxic supplies closet, and patio. Continue to LIC809-C. The Haven section has a cafe, activity room with sink, ocean room with balcony and fireplace, laundry room, trash closet, and electrical closet. A medication cart is in all three sections. All walkways, paths and passageways were clean, clear, and free of debris, hazards, and obstructions. The Executive Director and Associate Executive Director accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. Resident (rooms 100, 119, 128, 140, 203, 220, 232A, and 243) bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises. Resident bathrooms were checked. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, and hot water temperature properly measured at 116.0°F (room 100) and 116.7°F (room 243). Resident bath towels were adequately stocked. Common areas were clean and clear of hazards. Doorways were free of obstructions. LPA toured the kitchen area and observed a two-day supply of perishable and a seven-day supply of non-perishable food. Knives and toxins were kept in locked storage cabinet. First Aid kit was available. Redondo Beach Fire Department completed the facility’s fire and safety inspection on 10/03/2023. Continue to LIC809-C. Seven (7) staff records were reviewed and 7 out of 7 staff records had the required criminal record clearances or criminal record exemptions. Nine (9) resident records were reviewed and 9 out of 9 resident records had medical assessments and pre-appraisal or reappraisals. Three residents’ medication was reviewed. No deficiencies are being cited. An exit interview was conducted and a copy of this report was discussed and left with the Executive Director Robert May.the state’s words, verbatim · CDSS document, Jul 27, 2024