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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 107206939
Report Date: 04/08/2021
Date Signed: 04/08/2021 01:53:29 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
07/20/2020 and conducted by Evaluator Mary Garza
COMPLAINT CONTROL NUMBER: 24-AS-20200720131816
FACILITY NAME:KINGSTON BAY SENIOR LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:PAIGE WILLIAMSONFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 68DATE:
04/08/2021
UNANNOUNCEDTIME BEGAN:
11:14 AM
MET WITH:Administrator, Paige WilliamsonTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility staff did not administer medication in a timely manner
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
On 4/8/2021 Licensing Program Analyst (LPA) M. Garza conducted complaint investigation visit with the facility via tele-confrence to discuss complaint findings. Due to COVID 19 and pre-cautionary measures LPA identified self and discussed the purpose of the call with Administrator, Paige Williamson. Allegation was reviewed with Paige.

The Department investigated the above allegation. Based on interviews and records review, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did occur, therefore the allegation above found to be is found to be UNSUBSTANTIATED. Exit interview completed and appeal rights given.

A copy of the complaint investigation report was sent via email for signature. A delivery and read receipt were sent to serve as confirmation of reciept.
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Melinda HoffmannTELEPHONE: (559) 650-7914
LICENSING EVALUATOR NAME: Mary GarzaTELEPHONE: (559) 365-9009
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2021
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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