107206939-12-20-2023-24-AS-SPIY-CZ5MNH-20240103084534

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 12/20/2023
Date Signed: 12/20/2023 03:57:12 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
12/14/2023 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20231214111001

FACILITY NAME:	KINGSTON BAY SENIOR LIVING		FACILITY NUMBER:	107206939
ADMINISTRATOR:	ROBERT HUNTLEY		FACILITY TYPE:	740
ADDRESS:	6161 W SPRUCE AVE		TELEPHONE:	(559) 479-4700
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	128	CENSUS:	DATE:	12/20/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Rob Huntley		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Staff does not keep facility transportation bus clean
Infection Control Procedures are not in place

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial 10 - Day complaint inspection. LPA met with and explained the elements of the allegations with Administrator (AD) Rob Huntley.

During the visit, LPA toured the facility as well as the transportation van, conducted interviews and reviewed the facility Infection Control Plan and staff training logs.

Based on observation and interview, the transportantion van was not clean. Trash were observed throughout, van interior needs to be cleaned and items properly stored to promote safety.

Based on record review, staff have not completed required annual training in the area of Infection Control. The current Infection Control Plan needs to be updated. Five staff training files were reviewed during the visit.

See Lic9099-C for continuation of this report

Substantiated

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: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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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Control Number 24-AS-20231214111001

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: 12/20/2023

NARRATIVE

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The preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the areas of Maintenance and Operation and Infection Control Requirements

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed with and emailed to AD who signed the reports. Reports emailed to: rhuntley@kingstonbayliving.com

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20231214111001

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: 12/20/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 12/29/2023 Section Cited CCR 87303(a)	1 2 3 4 5 6 7	87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times... provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Administrator (AD) has agreed to develop a van maintenance procedure. Appropriate staff will be trained and a signed copy (AD, Maintenance Director and Driver) of the procedure will be emailed to CCLD by the POC date.
	8 9 10 11 12 13 14	Licensee did not ensure the facility van was maintained in a clean, safe and sanitary condition. Trash was observed and personal items are not properly stored. This poses a potential health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14	AD has agreed to conduct inservice and training to meet annual infection control requirements. Once complete, staff will sign a log with the DON. The complete log will be emailed to CCLD by the POC date.
Type B 12/29/2023 Section Cited CCR 87470(c)(1)(C)	1 2 3 4 5 6 7	87470 Infection Control Requirements (c) An Infection Control Plan shall be developed…by the licensee and shall (1) The Infection Control Plan shall include all of the following: (C) An Infection Control Training Plan. This requirement was not met as evidenced by:	1 2 3 4 5 6 7
	8 9 10 11 12 13 14	Licensee did not ensure all staff are trained as required in the area of Infection Control. Five staff training logs were reviewed during the visit. This poses a potential health, safety or personal rights risk to persona in care.	8 9 10 11 12 13 14

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 Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC9099 (FAS) - (06/04)

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