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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 04:46:19 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
12/06/2024 and conducted by Evaluator Katie Brown
PUBLIC
COMPLAINT CONTROL NUMBER: 24-AS-20241206171421
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:
02:14 PM
MET WITH:Rebecca LangdonTIME COMPLETED:
04:15 PM
ALLEGATION(S):
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Staff administered the incorrect medication to resident in care resulting in hospitalization.
Staff did not report an incident involving a resident as required.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct the initial 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.

The facility reported the incident that staff administered the incorrect medication to resident in care resulting in hospitalization on 10/1/24 to CCLD as required. A Case Management visit was conducted on 10/23/24 resulting in a citation in accordance with California Code of Regulations, 87465(a)(4) Incidental Medical and Dental Care.

The Department investigated the allegation: Staff did not report an incident involving a resident as required. The facility submitted Special Incident Reports (SIR) to CCLD as required which reported a medication error and that Resident (R1) experienced a fall resulting in medical attention and hospitalization.

See LIC9099C for continuation of this reoprt
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
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 3
Control Number 24-AS-20241206171421
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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It has been confirmed that the facility notified the Responsible Party (RP) via phone to report the fall and that R1 was being taken to the hospital via ambulance. Interviews reveal that the facility discovered the medication error after R1 had been transported. The facility called and reported the newly reported medication error to RP who was already at the hospital. The facility reported to RP via phone but did not provide a written report of the incidents.

Based on interview and record review, the preponderance of evidence standard has been met, therefore the above allegations are found to be SUBSTANTIATED.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D in the area of Reporting Requirements.



An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and emailed to AD at Blangdon@agemark.com
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
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: 2 of 3
Control Number 24-AS-20241206171421
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)
Request Denied
Type B
01/07/2025
Section Cited
CCR
87211(a)(1)(D)
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87211 Reporting Requirements (a) Each licensee shall furnish... (1) A written report shall be submitted to the licensing agency and to the person responsible for the resident... of the occurrence of any of (D) Any incident which threatens the welfare, safety or health of any resident…
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Licensee has agreed to review the current reporting procedure and update as needed. A copy of the updated procedure will be submitted to CCLD by poc date.
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This requirement was not met as evidenced by: Licensee did not ensure that a written report was provided to the Responsible Person of R1 after a medication error and fall resulting in hospitalization.
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.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
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: 3 of 3