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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 07/19/2023
Date Signed: 07/19/2023 10:31:47 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
03/24/2023 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20230324155306
FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 77DATE:
07/19/2023
UNANNOUNCEDTIME BEGAN:
09:21 AM
MET WITH:Leonel LopezTIME COMPLETED:
10:30 AM
ALLEGATION(S):
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Staff not administering residents medication as prescribed
Unqualified staff administering injections to residents
Staff are vaping while oxygen tanks are in use
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to deliver complaint investigation findings. LPA met with and explained the reason for the visit withAdministrator (AD) Rob Huntley and Director of Nursing (DON) Loenel Lopez.

The Department investigated the above allegations. A record review was conducted of the Medication Administration Record (MAR) which indicates that medications are routinely given to residents as scheduled. The MAR does not record the time the Med Tech (MT) documents. Based on record review of training logs and interviews reveal that MTs are trained to assist residents using the “Hand Over Hand Technique” when assisting with medications given via injection. Staff members interviewed deny knowing about or witnessing employees “Vaping” in the facility or Management offices. The facility policy strictly prohibits staff or residents smoking/vaping inside.

See LIC9099C for continuation of this report
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: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
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 2
Control Number 24-AS-20230324155306
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: 07/19/2023
NARRATIVE
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The above allegations are UNSUBSTANTIATED. Although the allegations may have happened or are valid, there is not a preponderance of evidence to prove that the alleged violations did or did not occur.


There were no citations issued

An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 07/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2