107206939-9-21-2022-24-AS-SPIY-CJXKG3-20221006075252

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:24:49 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
04/22/2022 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20220422110820

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: 86	DATE:	09/21/2022
		UNANNOUNCED	TIME BEGAN:	03:30 PM
MET WITH:	Christopher Smith		TIME COMPLETED:	04:40 PM

ALLEGATION(S):

1
2
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9

Questionable Death

INVESTIGATION FINDINGS:

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9
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13

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 allegation with Interim Administrator (AD) Christopher Smith.

The Department investigated the allegation: Questionable Death. Resident (R1's) facility file, hospice file and Death Certificate were reviewed. R1's cause of death is consistant with the primary hospice Diagnosis. Interviews were conducted with inconsistant reports of the situation leading up to R1's death. 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.

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (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)

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