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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:20:11 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
05/02/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220502094050
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: 86DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Christopher SmithTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Personal Rights
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the elements of the allegations with Interim Administrator (AD) Christopher Smith.

The Department investigated the allegation: Personal Rights (violation). A file review was conducted and revealed facility documentation of multiple episodes where R1's innapropriate outbursts and disturbances violated the rights of other residents who reside at the facility. Interviews confirm that on a regular and inpredictable basis, R1 yells, swears and belittles residents and staff in common areas of the facility making residents feel uncomfortable and disrespected. Based on file review and interviews, , the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

See LIC 9099-C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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
05/02/2022 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20220502094050

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: 86DATE:
09/21/2022
UNANNOUNCEDTIME BEGAN:
02:04 PM
MET WITH:Christopher SmithTIME COMPLETED:
03:30 PM
ALLEGATION(S):
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Resident needs a higher level of care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) arrived at the facility unannounced to conduct a subsequent complaint visit and deliver investigation findings. LPA met with and explained the elements of the allegations with Interum Administrator (AD) Christopher Smith.

The Department investigated the allegation: Resident needs a higher level of care. A file review was conducted and determined that R1's care needs are appropriate and could be met by the facility. Interviews revealed that R1 demonstrates inappropriate, disruptive behaviors on a regular basis in which are very disruptive to multiple residents. Facility interventions have not been successful. The facility has issued R1 a 30-Day notice. The allegation above is UNSUBSTANTIATED. Although the allegations may have happened or are valid there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No citation was issued for this allegation
An exit interview was conducted, and a copy of this report was left with AD, whose signature on this form confirm receipt of these documents.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
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-20220502094050
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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/30/2022
Section Cited
CCR
87468.1(a)(1)
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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other persons.
This requirement was not met as evidenced by:

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AD has agreed to provide inservice on resident altercations which occer in the facility and deescalation techniques. A staff sign in sheet with description of the topics as well as a copy of training materials. The proof of correction can be emailed to CCLD by 5PM 10//3/22
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Licensee did not ensure that residents in care were acaorded dignity in their personal relationships with staff... On multiple documented and reported occasions, R1 has demonstrated innapropriate behavior and verbal outbursts which were disruptive and disrespectful to residents and staff. Outbursts often consist of yelling, cussing or throwing items at others.
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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: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20220502094050
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: 09/21/2022
NARRATIVE
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A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.




An exit interview was conducted and Plans of Corrections were reviewed and developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirm receipt of these documents
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 4