107206939-4-8-2021-24-AS-SPIY-BZZNRB-20210412104116

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 04/07/2021
Date Signed: 04/08/2021 11:12:16 AM

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
01/26/2021 and conducted by Evaluator Darius Williams

PUBLIC

COMPLAINT CONTROL NUMBER: 24-AS-20210126144551

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: 68	DATE:	04/07/2021
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Administrator, Paige Williamson		TIME COMPLETED:	10:26 AM

ALLEGATION(S):

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Resident sustained serious injuries due to multiple falls.
Staff did not seek timely medical attention for residents.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Darius Williams conducted an unannounced complaint visit via telephone due to Covid-19 precautionary measures. LPA Williams spoke with Administrator, Paige Williamson and described the purpose of the visit; to deliver findings.

LPA Katie Brown previously investigated the allegation, staff did not seek timely medical attention for residents, regarding Resident 2 and delivered findings to the Licensee on 2/12/2021; refer to Complaint Control Number 24-AS-20201022145912.

Since LPA Brown previously investigated the allegation we have found that the current allegation, staff did not seek timely medical attention for residents, is UNFOUNDED, therefore we have dismissed the complaint.

*Continued on LIC9099-C*

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 24-AS-20210126144551

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: 04/07/2021

NARRATIVE

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LPA Williams conducted interviews and reviewed documents regarding the allegation, resident sustained serious injuries due to multiple falls.

Resident 1 (R1) facility progress notes reflect between 11/1/2020, and 11/12/2020, R1 was monitored for signs of bruising, bleeding, and loss of consciousness due to a prescribed medication. Progress notes reflect no signs of the symptoms.

Staff 3 (S3) reported R1 had an un-witnessed fall November 2020, on an unknown date. S3 stated there were no visible injures and R1 reported no injury to head. S3 and a Medical Technician monitored R1 for any delayed trauma.

According to R1’s facility progress notes, on 11/28/2020 R1 had one un-witnessed fall. No injuries were reported and R1 was monitored for delayed trauma.

On 11/29/2020, R1 was transported to the hospital due to confusion, weakness, and a temperature of 99 degrees Fahrenheit.

On 12/4/2020, R1's Power of Attorney reported R1 was positive for Covid-19 and had late stage Dementia.

This agency has investigated the complaint alleging resident sustained serious injuries due to multiple falls. We have found that the complaint was UNFOUNDED, meaning that the allegation is false, could not have happened, and/or is without a reasonable basis, therefore we have dismissed the complaint.

An exit interview was conducted and a copy of this report was provided via e-mail.

SUPERVISOR'S NAME: Serigy Pidgirny	TELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius Williams	TELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 04/07/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2021

LIC9099 (FAS) - (06/04)

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