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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 12/10/2024
Date Signed: 12/10/2024 05:14:43 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
10/22/2024 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241022083140
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:
12/10/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Rebecca LangdonTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Facility billed resident beyond the terms of the resident's Admission Agreement
Facility did not assess resident at hospital for a change of condition prior to discharge
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a subsequent complaint visit. LPA met with and explained the reason for the visit and the elements of the allegations with Interum Administrator (AD) Rebecca Langdon. LPA delivered investigation findings to the facility during this visit.

The Department investigated the allegation: Facility billed resident beyond the terms of the resident's Admission Agreement. R1 physically moved into the facility on 7/6/24. R1 was hospitalized 8/2-8/6/24.
Resident was sent back to the hospital 8/6/24 after being determined by the facility that R1's needs could no longer be met. R1 did not return to the facility. R1's apartment was vacated on 8/13/24. Interview and record review confirm that R1 was charged beyond the specifications of the Admission Agreement which was signed 6/28/24.

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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
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 4
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
10/22/2024 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241022083140

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:
12/10/2024
UNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:TIME COMPLETED:
04:15 PM
ALLEGATION(S):
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9
Facility unlawfully evicted resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a subsequent complaint visit. LPA met with and explained the reason for the visit and the elements of the allegations with Interum Administrator (AD) Rebecca Langdon. LPA delivered investigations to the facility during this visit.

This Department investigated the allegation: Facility unlawfully evicted resident. R1 returned from the hospital on 10/6/24. Due to R1's decline and change of condition, the facility was not able to provide the level of care R1 required. This is addressed on the attached LIC9099 under assessment of resident prior to return from the hospital. We have found that this 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 emailed to AD at Blangdon@agemark.com
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: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 2 of 4
Control Number 24-AS-20241022083140
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: 12/10/2024
NARRATIVE
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The Department investigated the allegation: Facility did not assess resident at hospital for a change of condition prior to discharge. R1 was hospitalized 8/2 - 8/6/24. Interview and record review of R1's hospital record confirm that the facility did not conduct a reappraisal prior to discharge. R1 returned the the facility 8/6/24 after a telephone update had been provided by hospital staff. Per interviews and review of Incident Report, staff and the Director of Nursing (DON) observed R1's decline and changes of condition after R1's return. At this time, the facility determined that R1's current care needs could not be met. R1 was sent back to the hospital on 8/6/24.

Based on interviews and record reviews, 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 Admission Agreements and Reappraisals.

An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were emailed to AD at Blangdon@agemark.com
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 4
Control Number 24-AS-20241022083140
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: 12/10/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2025
Section Cited
CCR
87507(f)
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87507 Admission Agreements (f) The licensee shall comply with all applicable terms and conditions set forth in the admission agreement, including all modifications and attachments. This requirement was not met as evidenced by:
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Licensee has agreed to refund half month of July rent as written in Reservation Agreement and level of care as of 8/7/24, base rent as of 8/14/24 and level of care rent 6/30-7/5/24. Additional reimbursements noted upon review will also be provided to R1. A copy of the reimbursement statement
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Licensee did not ensure compliance with all applicable terms of the Admission Agreement. R1 was not billed accurately according to the agreement after vacating the facility on 8/13/24.
This is a potential health & safety risk to persons in care.
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will be submitted to CCLD by poc date.
Type B
01/07/2025
Section Cited
CCR
87463(a)(3)
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87463 Reappraisals (a) The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes ... The reappraisals shall document changes in the resident's physical, medical,(3) Any illness, injury, trauma, or change in the health care needs…
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Licensee has agreed to review and revise procedures of resident assessment prior to return from a hospitalization. This procedure and will be emailed to CCL by the POC date.
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This requirement was not met as evidenced by: R1 was accepted back to the facility with significant changes of condition. The facility did not conduct an assessment prior to discharge from the hospital. This poses a potential health & safety risk to persons in care.

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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: 12/10/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC9099 (FAS) - (06/04)
Page: 4 of 4