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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 09/06/2024
Date Signed: 09/06/2024 03:13:20 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
05/08/2024 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20240508111233
FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Rob HuntleyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff does not provide residents clean linen
Staff does not ensure cleaning and hygiene products are inaccessible to residents
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley.

During this visit, LPA conducted interviews.

The Department investigated the allegation: Staff does not provide residents clean linen. On 8/12/24 Resident (R5’s) room was observed. R5’s bed sheets were found to be soiled with dried brown smears. Additionally, the same substance was observed on a shirt hanging in the closet and on the floor beside the bed. According to the housekeeping schedule, R5’s room had been cleaned (includes clean linens) on 8/10/24.

See LIC9099C for continuation of this report
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
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 6
Control Number 24-AS-20240508111233
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: 09/06/2024
NARRATIVE
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The Department investigated the allegation: Staff does not ensure cleaning and hygiene products are inaccessible to residents. On 8/12/24, resident hygiene products were observed in cabinets that were damaged or unlocked as well as body wash, shampoo, conditioner and mouth wash on the bathroom counters of residents in Memory Care with Dementia. On 9/7/24 conditioner was on the bathroom counter of R7 whose Physicians Report states cannot have access to hygiene and cleaning supplies.

The preponderance of evidence standard has been met, therefore the above allegations are 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 AD, whose signature on this form confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 6
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
05/08/2024 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20240508111233

FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Rob HuntleyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Resident developed dehydration while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent visit to deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley.

During this visit, LPA conducted interviews.

The Department investigated the allegation: Resident developed dehydration while in care.
A review of Resident (R1’s) medical records revealed R1 was admitted to Kaiser Hospital 4/24/24 - 4/27/2024. Facility reported R1 was not eating and had been vomiting. On 05/2/2024 R1 was readmitted after appearing lethargic and being nonresponsive. R1 had other diagnoses that could have contributed to the dehydration such as Covid-19 as recently as 4/18/24. R1’s Physician’s Report and Care Plan

See LIC9099C for continuation of this report



Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 6
Control Number 24-AS-20240508111233
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: 09/06/2024
NARRATIVE
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 note contradicting levels of staff assistance for eating. Other activities of daily living note extensive staff assistance required. The facility does not keep records of liquid intake, so it is unable to be determined R1’s fluid before and after hospitalization.

Based on interview and record review 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 and a copy of this report was left with AD, whose signature confirms receipt of these documents.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 6
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
05/08/2024 and conducted by Evaluator Katie Brown
COMPLAINT CONTROL NUMBER: 24-AS-20240508111233

FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: DATE:
09/06/2024
UNANNOUNCEDTIME BEGAN:
08:46 AM
MET WITH:Rob HuntleyTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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2
3
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Staff does not ensure resident's laundry is being met.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent visit to deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley.

The Department investigated the allegation: Staff does not ensure resident's laundry is being met.
Resident apartments and laundry rooms in Assisted Living (AL) and Memory care (MC) were observed. Appliances were in working order, supplies were observed and stored appropriately. The facility provided a schedule of housekeeping/laundry services for AL and MC. Interviews reveal that laundry is provided once a week and available as needed. AL residents report being satisfied with laundry service. MC rooms were observed to have adequate supply of towels and linens available as well as clothing put away. This Agency has investigated the allegation listed above. We have found that the allegation is UNFOUNDED, therefore we have dismissed the allegation.

There were no citations issued. An exit interview was conducted and a copy of this report was left with _____, whose signature confirms receipt of these documents.



Unfounded
Estimated Days of Completion:
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 5 of 6
Control Number 24-AS-20240508111233
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: 09/06/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/16/2024
Section Cited
CCR
87705(g)(1)
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87705 Care of Persons with Dementia (g)As required residents with dementia shall be allowed to keep personal grooming and hygiene items,. unless there is evidence… (1) Evidence means documentation from the resident’s physician... This requirement was not met as evidenced by:

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AD agrees to conduct an inservice to MC staff on proper storage of hygiene items of residents with Dementia. Proof of in-service (sign in sheet) will be submitted to CCLD by poc date.
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Licensee did not ensure hygiene supplies were inaccessable to residents. On 8/12/24 shampoo, conditioner, moulth wash were accessible in the bathrooms of R3 and R7. 9/5/25, conditioner was accessable in the bathroom of R7. R7's Physicians Report says R7 is at risk if accessible.
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Type B
09/16/2024
Section Cited
CCR
87303(a)
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87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement was not met as evidenced by:
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Licensee did not ensure that R5's bed linens were clean. Dry brown smears were observed on the sheets and floor. A damaged nightstand was observed ias well as damaged bathroom door frame in R7's room. This poses a potential health and safety risk to persons in care.
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AD has agreed to in-service MC staff on housekeeping procedures and practice. Proof of inservice will be submitted to CCLD by poc date.
The flooring in R5's room has been replaced, the nightstand was immediately removed from R7's room. Doorway has also been repaired.
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 PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 09/06/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2024
LIC9099 (FAS) - (06/04)
Page: 6 of 6