107206939-3-23-2021-24-AS-SPIY-BZZNTJ-20210412104450

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 03/22/2021
Date Signed: 03/23/2021 03:48:34 PM

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
12/15/2020 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20201215102218

FACILITY NAME:	KINGSTON BAY SENIOR LIVING		FACILITY NUMBER:	107206939
ADMINISTRATOR:	PAIGE WILLIAMSON		FACILITY TYPE:	740
ADDRESS:	6161 W SPRUCE AVE		TELEPHONE:	(559) 479-4700
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	128	CENSUS: 69	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Paige Williamson		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
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5
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7
8
9

Staff did not respond to call button in a timely manner

INVESTIGATION FINDINGS:

1
2
3
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5
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7
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9
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12
13

Licensing Program Analyst (LPA) Katie Brown contacted the Administrator, Paige Williamson via telephone to deliver the investigation findings due to COVID-19 and pre-cautionary measures.

The Department has investigated the complaint alleging: Staff did not respond to call button in a timely manner. Based on interview conducted with the Administrator and RP as well as records review which included text messages between R1 and RP we are unable to determine that the allegation occurred.
The records review included facility Progress Notes, R1’s Physician's Report, Service Plan (including facility conducted assessments), Admission Agreement, text messages and email provided by RP. The facility was not able to access R1’s call button history in provided timeframe of the text messages.

The allegation is UNSUBSTANTIATED. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove that the alleged violation did or did not occur.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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

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
12/15/2020 and conducted by Evaluator Katie Brown

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20201215102218

FACILITY NAME:	KINGSTON BAY SENIOR LIVING		FACILITY NUMBER:	107206939
ADMINISTRATOR:	PAIGE WILLIAMSON		FACILITY TYPE:	740
ADDRESS:	6161 W SPRUCE AVE		TELEPHONE:	(559) 479-4700
CITY:	FRESNO	STATE: CA	ZIP CODE:	93722
CAPACITY:	128	CENSUS: 69	DATE:	03/22/2021
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Administrator, Paige Williamson		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff failed to inform responsible party of change in resident's condition.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Katie Brown contacted the Administrator, Paige Williamson via telephone to deliver the investigation findings due to COVID-19 and pre-cautionary measures.

The Department has investigated the complaint alleging: Staff failed to inform responsible party of change in resident's condition. Based on interview of FM1, Administrator, S1, S2 and S3 it was determined that the facility used the Lic. 601 Identification and Emergency Information form completed at R1’s admission to determine the Responsible Party. Per the facility policy “Change in Resident Status”, the designated facility staff will notify the family/Responsible person of a change in status/condition. FM1 is named on the Lic. 601 as Responsible Party. Power of Attorney (POA) documentation was not provided to the facility that would have changed the Responsible Party from FM1 to RP prior to R1’s death. Based on records review of R1’s admission paperwork, facility Progress Notes and the facility policy, it was determined that the facility did report changes in resident condition to the appropriate Responsible Party. We have determined that the complaint was UNFOUNDED, therefore we have dismissed the complaint.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2021

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 2