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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 05/23/2025
Date Signed: 07/01/2025 12:20:06 PM

Substantiated


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
02/25/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250225081339
FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 87DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jami Young, Director of Nursing (DON)TIME COMPLETED:
04:00 PM
ALLEGATION(S):
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Staff handles residents in a rough manner
Staff speak inappropriately to residents in care
Staff do not have required qualifications
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit and the elements of the allegations with Jami Young, DON.

This Department investigated the allegations Staff handles residents in a rough manner and Staff speak inappropriately to residents in care. Residents' R1, R2 and R4's statements were consistent during interviews that Staff S1 has been rough while providing care, S1 has spoken to residents in an intimidating, inappropriate manner. Residents report not wanting S1 to care for them.

See LIC9099C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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 4
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
02/25/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250225081339

FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 87DATE:
05/23/2025
UNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Jami Young, Director of Nursing (DON)TIME COMPLETED:
04:00 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Staff did not notify resident's responsible party of fall
INVESTIGATION FINDINGS:
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13
Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deviver complaint findings. LPA met with and explained the reason for the visit and the elements of the allegations with Jami Young, DON.

The Department investigated the allegation: Staff did not notify resident's responsible party of fall. On 9/14/24, an incident occurred in the parking lot of the facility resulting in R3 falling out of the motorized sccoter. LPA reviewed facility reports and confirmed with R3's Responsible Party that they were notified of the fall and incident. The Responsible Party's version and the facility reports information were not consistent. This Department was unable to reach the family of R3 for clarification.Based on interview and record review the above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

There were no citations issued. An exit interview was conducted and a copy of this report was left with DON.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
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 4
Control Number 24-AS-20250225081339
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
VISIT DATE: 05/23/2025
NARRATIVE
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Continuation - Page 2


This Department investigated the allegation: Staff do not have required qualifications. S3 was originally hired in Housekeeping. Interview and review of a staff schedule reveal that S3 began working as a caregiver in November 2024. Based on record review of S3's "User Learning", S3 did not complete the training requirements prior to working as a care provider. Additionally, S3's employee file was reviewed no record of First Aid Certification was located. The preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with DON.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20250225081339
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: 05/23/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/02/2025
Section Cited
CCR
87468.1
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87468.1 Personal Rights...(a)...shall have the following personal rights (1)... .accorded dignity in their personal relationships with staff, residents, and other persons.This requirement was not met as evidenced by: Residents confirm S1 speaks in a demeaning manner and is rough causing discomfort during care. This is a potential health & safety risk to persons in care.
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Administrator has agreed to submit a written plan of action which will include a training plan. The written plan will be submitted to CCLD by poc date.
Type B
06/02/2025
Section Cited
CCR
87411(c)
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87411 Personnel Requirements... (c) All RCFE staff... who assist residents with personal activities of daily living shall receive initial and annual training... This requirement was not met as evidenced by: S3 worked as a caregiver without completing RCFE requirements and without First Aid/CPR Certification. This is a potential health & safety risk to persons in care.
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Administrator has agreed to review the care staff training procedure with DON. A written statement will be submitted that the procedure has been reviewed and updated if needed. This statement will be signed by AD and DON and submitted to CCLD by poc date
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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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 05/23/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/23/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 4