107206939-8-12-2024-24-AS-SPIY-D8DT3U-20240822142255

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:23:26 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
04/04/2024 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20240404121910

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: 91	DATE:	08/12/2024
		UNANNOUNCED	TIME BEGAN:	11:16 AM
MET WITH:	Robert Huntley		TIME COMPLETED:	03:15 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff did not prevent inappropriate interactions between residents in care
Staff did not following reporting requirements

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley.

This Department investigated the allegation: Staff did not prevent inappropriate interactions between residents in care. Interviews and record reviews reveal the following incidents: On 3/13/23 staff found R1 unclothed in R2’s room. On 3/15/24, R1 was found by staff in R1’s bedroom, sitting on a char, covered in a bedsheet and R1’s feet were bound resulting in bruising. On 3/20/24, R2 was observed pulling R1 into a chair. On 3/21/24, R1 was found In R2’s bedroom, R2 was preventing R1 from exiting. On 3/27/24 R1’s feet had been tied together with clothing. On 3/28/24, R1 was found in R2’s bed topless and R1’s undergarment had been removed. R1 and R2 both have Dementia and reside in the Memory Care Unit. Once the facility was made aware of R2’s behavior, precautions were not put in place to ensure the safety of R1 and other residents.
See LIC9090C 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: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

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 3

Control Number 24-AS-20240404121910

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: 08/12/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Based on record review of Special Incident Reports (SIRs), facility staff observations and interviews, it is confirmed that R1 has aggressive and sexualized behaviors, but no safety plan was put in place.

This Department investigated the allegation: Staff did not following reporting requirements. Record review of staff observations reveal that incidents occurred between R1 and R2 were not reported as required. The facility did not submit SIRs or reports of suspected abuse (SOC 341) as required for incidents which occurred on 3/13/24, 3/21/24 and 3/27/24. The incidents resulted unsafe, inappropriate interactions between R1 and R2. Additionally, facility did not report an incident which occurred 3/28/24 between R1 and R2 to law enforcement until the following day. Interviews reveal that that staff reported incidents and concerns to which were not reported to CCLD, Ombudsman or Law Enforcement as required.

Based on record review and interviews, 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 Basic Services and Reporting Requirements.

An Immediate Civil penalty is assessed on the attached LIC421IM for absence of care and supervision.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD whose signature on this form confirms receipt of these documents.

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:	DATE: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 24-AS-20240404121910

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: 08/12/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/13/2024 Section Cited CCR 87464(f)(1)	1 2 3 4 5 6 7	87464 Basic Services (f) Basic services shall at a minimum include: (1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:	1 2 3 4 5 6 7	AD has agreed to submit a written statement which outlines inservice for staff on care and supervision based on the regulations. Additionally, AD will include the steps to conduct a staffing review in MC. The statement will be submitted by 8/13/24. AD will include a
	8 9 10 11 12 13 14	Licensee did not ensure R1's physical health, mental health, safety, or welfare once aware of the behaviors of R2. The facility did not prevent multiple incidents of innapropriate interactions between R1 and R2. This poses an immediate health and safety risk to persons in care.	8 9 10 11 12 13 14	date that the findings of a staff review will be submitted, no later than 30 days.
Type B 08/26/2024 Section Cited CCR 87211(a)(1)(D)	1 2 3 4 5 6 7	87211 Reporting Requirements (a) Each licensee shall furnish to the licensing agency... (1) A written report shall be submitted to the licensing agency... within seven days…(D) Any incident which threatens the welfare, safety or health of any resident... This requirement was not met as evidenced by:	1 2 3 4 5 6 7	AD has agreed to provide in-service on reporting requirements to theNursing staff. Additionally, all care staff will be inserviced on Mandating Reporting Requirements. Proof of these trainings will be submitted on a sign in sheet with names and signatures by the poc date.
	8 9 10 11 12 13 14	Licensee did not ensure that Incident reports were submitted as required after incidents occurred which threatens the welfare, safety or health of R1.	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: 08/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/12/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 3