107206939-12-1-2023-24-AS-SPIY-D49LGF-20240412084439

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 11/30/2023
Date Signed: 12/01/2023 09:49:38 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
11/20/2023 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20231120094937

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: 81	DATE:	11/30/2023
		UNANNOUNCED	TIME BEGAN:	09:47 AM
MET WITH:	Rob Huntley		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Staff are not meeting residents incontinence needs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a 10-Day initial complaint investigation. LPA met with and discussed the allegation with Administrator (AD) Rob Huntley and Director Of Nursing (DON) Leonel Lopez, LVN.

During the visit, LPA conducted interviews and record review. Interviews reveal that Resident (R1) is independent of Activities of Daily Living (ADLs). Per AD and DON, the facility is aware of the change in R1's needs and increased odor which bother other residents in common areas. R1's care plan is in process of being updated though interventions are in process of being implemented. The above allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation 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.

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: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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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