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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 10/29/2020
Date Signed: 10/30/2020 10:02:56 AM



STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2020 and conducted by Evaluator See Moua
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200506162230
FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:PAIGE WILLIAMSONFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 70DATE:
10/29/2020
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Paige Williamson, Administrator TIME COMPLETED:
09:24 AM
ALLEGATION(S):
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Staff did not administer medications as prescribed by a physician.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) S. Moua contacted the facility via telephone to commence a subsequent complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the allegation and findings with Administrator Paige A Williamson.

Facility staff and residents were interviewed. Staff and resident confirmed that resident’s morning medications were administered more than an hour after the prescribed time because there was only one Med-Tech on duty on 5/6/2020 and she fell behind. Medications were not administered as prescribed. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. See citation on the attached LIC. 9099D. Exit Interview was conducted and Appeal Rights were provided.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
This is an official report of an unannounced visit/investigation of a complaint received in our office on
05/06/2020 and conducted by Evaluator See Moua
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20200506162230

FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:PAIGE WILLIAMSONFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 70DATE:
10/29/2020
UNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:Paige Williamson, Administrator TIME COMPLETED:
09:24 AM
ALLEGATION(S):
1
2
3
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5
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8
9
Insufficient staff to meet residents' needs.
INVESTIGATION FINDINGS:
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5
6
7
8
9
10
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12
13
Licensing Program Analyst (LPA) S. Moua contacted the facility via telephone to commence a subsequent complaint investigation via telephone due to COVID-19 and pre-cautionary measures. LPA identified herself and discussed the allegation and findings with Administrator Paige A Williamson.

Facility staff and residents were interviewed. Residents that were interviewed denied that needs are not being met. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is Unsubstantiated. Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 24-AS-20200506162230
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: KINGSTON BAY SENIOR LIVING
FACILITY NUMBER: 107206939
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/29/2020
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/30/2020
Section Cited
CCR
87465(a)(2)
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Incidental Medical and Dental Care The licensee shall provide assistance in meeting necessary medical and dental needs. This requirement was not met as evidenced by:
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Administrator agree to conduct In-Service training to staff regarding administering medications on time. POC will be submitted to the CCL Office by the due date.
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Based on interviews conducted, the facility failed to administer residents’ morning medications as prescribed by a physician, which poses an Immediate Health and Safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Andy XiongTELEPHONE: (559) 650-7904
LICENSING EVALUATOR NAME: See MouaTELEPHONE: (559) 650-7904
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2020
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2020
LIC9099 (FAS) - (06/04)
Page: 3 of 3