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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 10/23/2024
Date Signed: 10/23/2024 02:48:23 PM


Document Has Been Signed on 10/23/2024 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710



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: 91DATE:
10/23/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
01:43 PM
MET WITH:Rob HuntleyTIME COMPLETED:
03:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arived unannounced to conduct a Case Management visit. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley and Assistant Director of Nursing (ADON) Gaberiel Facio, LVN.


The facility submitted Special Incident Reports (SIRs) which resulted in medication errors.
On 9/29/24, Resident (R1) was given the wrong medication (another resident's medication).
On 10/1/24, Resident (R2) was also given another resident's medication. R2 later experienced a fall and was evaluated at the hospital.


A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the area of Incidental Medical and Dental Care.

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: 10/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/23/2024 02:48 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/23/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/24/2024
Section Cited
CCR
87465(a)(4)

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87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care... by compliance with the following: (4) The licensee shall assist residents with self-administered medications as needed. This requirement was not met as evidenced by:
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AD has agreed to conduct a Med Tech in-service to review facility medication assistance procedures. AD will submit a written statement which includes the training plan and timeline of no more than 1 week. The inservice sign in will be submitted to CCL which includes names and signatures.
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Licensee did not ensure that the facility Med Tech assisted R1 and R2 with self-administered medications as ordered by their Physicians. R1 and R2 were given other resident's medications by facility Med Techs. R2 fell and required medical care.This poses an immediate health & safety risk to residents in care.
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Written statement to be submitted by poc date.

Sign in sheet to be submitted after completion of training.

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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.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2024
LIC809 (FAS) - (06/04)
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