107206939-5-23-2025-24-AS-SPIY-DHLKB4-20250613074451

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 05/23/2025
Date Signed: 05/23/2025 06:33:46 PM

Unsubstantiated

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
02/21/2025 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20250221153510

FACILITY NAME:	KINGSTON BAY SENIOR LIVING		FACILITY NUMBER:	107206939
ADMINISTRATOR:	ROBERT HUNTLEY		FACILITY TYPE:	740
ADDRESS:	6161 W SPRUCE AVE		TELEPHONE:	(559) 479-4700
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	128	CENSUS: 87	DATE:	05/23/2025
		UNANNOUNCED	TIME BEGAN:	03:45 PM
MET WITH:	Jami Young, Director of Nursing (DON)		TIME COMPLETED:	06:40 PM

ALLEGATION(S):

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Staff does not ensure facility has adequate staffing to meet resident's needs
Facility has pests
Facility staff did not seek timely medical attention for resident
Facility staff did not observe resident's change in condition

INVESTIGATION FINDINGS:

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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.

This Department investigated the allegation: Staff does not ensure facility has adequate staffing to meet resident's needs. Staff Schedule and time cards were reviewed for identified dates. Interviews reveal that there are shifts where there is 1 caregiver and on each floor of the Assisted Living portion of the facility. Between 2/15 - 2/16/25 Resident R1 experienced falls requiring hospitalization. It is unknown if the falls are related to lack of staff and supervision.

See LIC9099C for continuation of this report

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)

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Control Number 24-AS-20250221153510

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: Facility has pests. The facility has a contract with Ecolab Pest Service. Receipts of service were provided and reviewed. There is a log maintained at the front desk where staff and family can report pests and request service. Facility maintenance or Ecolab sign off once the issue has been addressed. Sticky pads were observed in room 219 which are used as bait for roaches. Though small bugs were observed there is a procedure in place to address when identified.

The Department investigated the allegations: Facility staff did not seek timely medical attention for resident and Facility staff did not observe resident's change in condition. Record review was conducted of R1's file and facility Observation Notes. The review confirmed that R1 had continued to become increasingly confused from 2/14-2/16/25. The notes show that facility staff communicated multiple times with R1's Responsible Party with updates on R1's increasing confusion including a fall on 2/15/25. Per the notes, Responsible Party repeatedly refused to send R1 to the hospital. It wasn't until R1 fell with injury and Paramedics spoke to Responsible Party that it was agreed that R1 would go to the hospital.

The above allegations are 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.

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)

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