107206939-1-8-2024-24-AS-SPIY-CZMLJ3-20240119074716

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 01/08/2024
Date Signed: 01/08/2024 04:11:30 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
09/19/2023 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20230919144634

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:	01/08/2024
		UNANNOUNCED	TIME BEGAN:	11:50 AM
MET WITH:	Leonel Lopez		TIME COMPLETED:	03:40 PM

ALLEGATION(S):

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1. Questionable Death
2. Staff handle residents in a rough manner causing bruising
3. Staff do not distribute medication to residents as prescribed
4. Staff did not seek medical attention for resident in a timely manner

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Director of Nursing (DON) Leonel Lopez. During this visit, LPA interviewed DON, reviewed/obtained copies of resident files and interviewed residents.

1. The Department conducted a record review of Resident (R1's) facility file and obtained hospital medical records. R1 was admitted to the hospital 9/13/23. Staff charting notes 7/3/23-9/13/23 document R1's symptoms and changes as well as communication with family and physician. Medical records from the hospital do not mention suspision of abuse or neglect.
2. Based on interview, staff members do not report unknown bruising or injuries. Interviews reveal that if injury or bruising is noted, there is a reporting procedure. Residents were also interviewed and denied staff handeling them roughly. The resident noted by the Reporting Party passed away prior to the start of this investigation.

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: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

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-20230919144634

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: 01/08/2024

NARRATIVE

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3. A record review was conducted of the Medication Administration Records (MARs) of the identified residents, including physician's orders. Residents were interviewed who state that they are assisted with/provided medications daily. Two of the residents identified passed away prior to the start of this investigation and another was independent in medication management at the time. Facility "Med Techs" were interviewed and medication procedure was reviewed.

4. A record review of facility documentation including "Observation Notes" (Med Tech charting) for R1 and R5 was conducted. Staff documented R1's symptoms and changes leading up to hospitalization on 9/13/23. R5's Observation notes as well as internal reports were reviewed and show that R5 sustained two falls, refused to be hospitalized and received X-Rays as ordered by Physician.

Based on interview, record review and observation, 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 with DON and Administrator (AD) Rob Huntly. The report was signed by AD and emailed to rhuntly@kingstonbayliving.com.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 01/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024

LIC9099 (FAS) - (06/04)

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