107206939-6-15-2022-24-AS-SPIY-CFMKVF-20220622081414

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 06/14/2022
Date Signed: 06/15/2022 07:39:24 AM

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
01/19/2022 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220119090316

FACILITY NAME:	KINGSTON BAY SENIOR LIVING		FACILITY NUMBER:	107206939
ADMINISTRATOR:	PAIGE WILLIAMSON		FACILITY TYPE:	740
ADDRESS:	6161 W SPRUCE AVE		TELEPHONE:	(559) 479-4700
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	128	CENSUS: 79	DATE:	06/14/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Lai Saeteum		TIME COMPLETED:	04:15 PM

ALLEGATION(S):

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Facility does not ensure that resident is hydrated

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the purpose of the visit with Lai Saeteurn, Associate Executive Director (AED).

LPA observed water stations throughout the facility. Interviews were conducted. It was consistently reported that residents are provided water and juice with each meal. Additionally, water is presented before the meal to promote consumption. Residents are offered beverages during activities and snack times between meals. Interviews revealed that the amount of water/liquids consumed daily by residents is not tracked. Staff are trained to look for signs and symptoms of Dehydration. Based on observations and interviews conducted, the allegation is UNSUBSTANTIATED. Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

A copy of this report was emailed to aed@kingstonbayfresno.com. An exit interview was conducted with Lai Saeteurn.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022

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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