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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 12/12/2025
Date Signed: 12/12/2025 01:17:29 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
07/24/2025 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20250724162450
FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:DENNIS, SARAHFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 87DATE:
12/12/2025
UNANNOUNCEDTIME BEGAN:
10:12 AM
MET WITH:Jami Young, Director of NursingTIME COMPLETED:
01:25 PM
ALLEGATION(S):
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Staff exposed themselves to a resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit. LPA met with and explained the reason for the visit with Director of Nursing (DON) Jami Young, LVN. During this visit, LPA interviewed DON, obtained documents and delivered investigation findings.

This Department investigated the allegation above. Interview and documentation provided by the facility confirm that Staff (S1) admitted that inappropriate interaction occurred in the presence of R1. The preponderance of evidence standard has been met; therefore, the above allegation is found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with DON, Jami Young, LVN.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
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 2
Control Number 24-AS-20250724162450
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: 12/12/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/22/2025
Section Cited
CCR
87468.1(a)(1)
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Personal Rights of Residents in All Facilities 87468.1 (a) Residents in all residential care facilities... (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by

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Administrator (AD) has agreed to provide staff inservice on Resident Personal Rights and Mandated Reporting. Inservice will include: Staff are provided a copy of LIC613C-2 (3/25) which will be reviewed. Additionally, Mandated Reporter requirements will be reviewed.
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Licensee did not ensure R1 was accorded dignity in their personal relationships with staff. After R1 reported to DON, S1 admitted to an inappropriate interaction of body exposure to R1 during care. This poses a potential health and safety risk to persons in care.
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A sign in sheet with nsmes and signatures of all AL and MC staff as well as a copy of training materials will be provided to CCLD via email by poc date.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2