107206939-3-19-2021-24-AS-SPIY-BZDSSG-20210323140756

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 03/19/2021
Date Signed: 03/19/2021 02:38:35 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
07/07/2020 and conducted by Evaluator Les Xiong

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20200707110009

FACILITY NAME:	KINGSTON BAY SENIOR LIVING		FACILITY NUMBER:	107206939
ADMINISTRATOR:	PAIGE WILLIAMSON		FACILITY TYPE:	740
ADDRESS:	6161 W SPRUCE AVE		TELEPHONE:	(559) 479-4700
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	128	CENSUS: 68	DATE:	03/19/2021
		UNANNOUNCED	TIME BEGAN:	01:33 PM
MET WITH:	Paige Williamson		TIME COMPLETED:	03:04 PM

ALLEGATION(S):

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9

Facility does not have adequate staffing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) L. Xiong called and spoke with Administrator Paige Williamson regarding the complaint allegation(s). Finding(s) were delivered over the phone due to COVID 19 precautionary guidelines.

During the course of this investigation LPA reviewed records obtained from the facility, interviewed staffs and residents relevant to the complaint investigation. It was determined that the above allegation(s): Facility does not have adequate staffing is UNFOUNDED. R1, R2 & R3 confirmed staff responds promptly when called and they do not have issues with care. This agency has investigated the complaint alleging (Facility does not have adequate staffing). We have found that the complaint was unfounded, therefore we have dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Les Xiong	TELEPHONE: (559) 410-1772
LICENSING EVALUATOR SIGNATURE:	DATE: 03/19/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/19/2021

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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