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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 02/12/2021
Date Signed: 02/23/2021 03:21:19 PM



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
10/22/2020 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20201022145912
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: DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Paige WilliamsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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9
Staff did not seek medical attention for resident in a timely manner.
INVESTIGATION FINDINGS:
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13
The Department has investigated the allegation that staff did not seek medical attention for R1 in a timely manner. Based on interviews conducted and record/medical review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED.

See 9099-D for deficiency and Plan of Correction.
Appeal Rights provided. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
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
Control Number 24-AS-20201022145912
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: 02/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/16/2021
Section Cited
CCR
87465(g)
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87465 Incidental Medical and Dental Care
(g)The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis except as specified in Sections 87469(c)(2), (c)(3), or (c)(4).

*This requirement was not met as evidenced by:
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1) Licensee will provide a written statement that training will be provided to all staff who provide care to residents on the facility Emergency Response Policy by 2/16/2021.

2) Licensee will provide LPA a training roster which will include the name, signature and date off all staff members (who provide care and supersivion to residents) as proof of training of the facility Emergency Response Policy by 2/19/2021
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The facility staff did not call 911 when R1 stated she believed she was having a Heart Attack. R1 as well as the RP requested 911 be called.

**This presents an immediate risk to the health and safety of the persons in care.
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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) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
LIC9099 (FAS) - (06/04)
Page: 2 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
10/22/2020 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20201022145912

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: DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Paige WilliamsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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2
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9
Questionable Death
Staff did not notify resident's authorized representative of change in health condition in a timely manner
Staff failed to meet resident's needs

INVESTIGATION FINDINGS:
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The Department has investigated the allegation of questionable death. The Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

The Department has investigated the allegation of staff did not notify resident's authorized representative of change in health condition in a timely manner. The Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

The Department has investigated the allegation of Staff failed to meet resident's needs. This specific allegation has been addressed through the investigation of another allegation in this complaint. The Department has found that the complaint is UNFOUNDED, meaning that the allegation was false, could not have happened and/or is without reasonable basis. We have therefore dismissed the complaint.

Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 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
10/22/2020 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20201022145912

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: DATE:
02/12/2021
UNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Paige WilliamsonTIME COMPLETED:
03:00 PM
ALLEGATION(S):
1
2
3
4
5
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7
8
9
Staff are not properly trained.
INVESTIGATION FINDINGS:
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The Department has investigated the allegation that staff are not properly trained. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation is UNSUBSTANTIATED.

Exit Interview conducted.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 02/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/12/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 4