Kingston Bay Senior Living

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not maintain a comfortable temperature for residents in care Staff are not following the facility menu

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial complaint visit. LPA met with and explained the reason for the visit and reviewed the allegations with Administrator (AD) Sarah Dennis and Director of Nursing (DON) Jami Young, LVN. During the visit, LPA conducted interviews, record reviews, observed lunch service and toured the kitchen. This Department investigated the allegations noted above. Interviews with AD and DON reveal that each resident has 1-2 Air conditioning units in their apartments. Residents reported their rooms being maintained at a comfortable temperature and if there is an issue, a work order can be made at the front desk. A record review was conducted of the work order log. There are work order entries "AC not working" that are "open" ranging from 1-7 days. In multiple apartments toured, the resident did not have the thermostat set correctly or even set to on. See LIC 9099C for Continuation of this report Unsubstantiatedthe state’s words, verbatim · CDSS document, Sep 11, 2025 · control 24-AS-20250902090350

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Facility staff are not meeting resident toileting needs Facility staff do not respond to residents call buttons in timely manner Facility staff are not dispensing medication as prescribed

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a subsequent visit and derived complaint findings. LPA met with and explained the reason for the visit with Assistant Director of Nursing (ADON) Frankie Tamayo. Administrator (AD) Sarah Dennis arrived a short time later. During this visit, LPA conducted interviews, and reviewed Resident (R1's) medications. This Department investigated the following allegations: Facility staff are not meeting resident toileting needs: A record review was conducted of R1's file. Service Plan dated 3/27/25 which states R1 is independent with toileting, no assistance needed by staff. Physician Report dated 11/2024 - able to care for own toileting needs and transfers self. Per staff interview, staff assist R1 with the bedtime routine and may help with a nighttime brief. Unsubstantiatedthe state’s words, verbatim · CDSS document, Jul 18, 2025 · control 24-AS-20250320121934

Allegation investigated: Staff handled resident in a rough maner resulting in a skin tear

Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility unannounced to conduct an initial complaint investigation. LPA met with and explained the reason for the visit and the allegation with Administrator (AD) Sarah Dennis. During this visit, LPA also delivered investigatigation findings. On 5/25/25 around 4:00 AM, Staff S1 called for assistance because Resident R1 was being physically aggressive. S1 pulled R1 by the legs and then by the arms to move R1 away from R2 which caused R1 to sustain a skin tear on the right arm. Based on interviews conducted and staff statements reviewed, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 9099-D. An exit interview was conducted and Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD. Substantiatedthe state’s words, verbatim · CDSS document, May 28, 2025 · control 24-AS-20250527121130

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not ensure facility has adequate staffing to meet resident's needs Facility has pests Facility staff did not seek timely medical attention for resident Facility staff did not observe resident's change in condition

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deviver complaint findings. LPA met with and explained the reason for the visit and the elements of the allegations with Jami Young, DON. This Department investigated the allegation: Staff does not ensure facility has adequate staffing to meet resident's needs. Staff Schedule and time cards were reviewed for identified dates. Interviews reveal that there are shifts where there is 1 caregiver and on each floor of the Assisted Living portion of the facility. Between 2/15 - 2/16/25 Resident R1 experienced falls requiring hospitalization. It is unknown if the falls are related to lack of staff and supervision. See LIC9099C for continuation of this report Unsubstantiatedthe state’s words, verbatim · CDSS document, May 23, 2025 · control 24-AS-20250221153510

Allegation investigated: Staff handles residents in a rough manner Staff speak inappropriately to residents in care Staff do not have required qualifications

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit and the elements of the allegations with Jami Young, DON. This Department investigated the allegations Staff handles residents in a rough manner and Staff speak inappropriately to residents in care. Residents' R1, R2 and R4's statements were consistent during interviews that Staff S1 has been rough while providing care, S1 has spoken to residents in an intimidating, inappropriate manner. Residents report not wanting S1 to care for them. See LIC9099C for continuation of this report Substantiatedthe state’s words, verbatim · CDSS document, May 23, 2025 · control 24-AS-20250225081339

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: 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

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 Substantiatedthe state’s words, verbatim · CDSS document, Dec 10, 2024 · control 24-AS-20241022083140

Allegation investigated: Staff administered the incorrect medication to resident in care resulting in hospitalization. Staff did not report an incident involving a resident as required.

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 continuatithe state’s words, verbatim · CDSS document, Dec 10, 2024 · control 24-AS-20241206171421

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff does not provide residents clean linen Staff does not ensure cleaning and hygiene products are inaccessible to residents

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent visit and deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley. During this visit, LPA conducted interviews. The Department investigated the allegation: Staff does not provide residents clean linen. On 8/12/24 Resident (R5’s) room was observed. R5’s bed sheets were found to be soiled with dried brown smears. Additionally, the same substance was observed on a shirt hanging in the closet and on the floor beside the bed. According to the housekeeping schedule, R5’s room had been cleaned (includes clean linens) on 8/10/24. See LIC9099C for continuation of this report Substantiatedthe state’s words, verbatim · CDSS document, Sep 6, 2024 · control 24-AS-20240508111233

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: Staff did not prevent inappropriate interactions between residents in care Staff did not following reporting requirements

Licensing Program Analyst (LPA) Katie Brown arrived at the facility to deliver complaint findings. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley. This Department investigated the allegation: Staff did not prevent inappropriate interactions between residents in care. Interviews and record reviews reveal the following incidents: On 3/13/23 staff found R1 unclothed in R2’s room. On 3/15/24, R1 was found by staff in R1’s bedroom, sitting on a char, covered in a bedsheet and R1’s feet were bound resulting in bruising. On 3/20/24, R2 was observed pulling R1 into a chair. On 3/21/24, R1 was found In R2’s bedroom, R2 was preventing R1 from exiting. On 3/27/24 R1’s feet had been tied together with clothing. On 3/28/24, R1 was found in R2’s bed topless and R1’s undergarment had been removed. R1 and R2 both have Dementia and reside in the Memory Care Unit. Once the facility was made aware of R2’s behavior, precautions were not put in place to ensure the sthe state’s words, verbatim · CDSS document, Aug 12, 2024 · control 24-AS-20240404121910

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.

Allegation investigated: . Questionable Death 2. Staff handle residents in a rough manner causing bruising 3. Staff do not distribute medication to residents as prescribed 4. Staff did not seek medical attention for resident in a timely manner

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a subsequent complaint visit and deliver complaint findings. LPA met with and explained the reason for the visit with Director of Nursing (DON) Leonel Lopez. During this visit, LPA interviewed DON, reviewed/obtained copies of resident files and interviewed residents. 1. The Department conducted a record review of Resident (R1's) facility file and obtained hospital medical records. R1 was admitted to the hospital 9/13/23. Staff charting notes 7/3/23-9/13/23 document R1's symptoms and changes as well as communication with family and physician. Medical records from the hospital do not mention suspision of abuse or neglect. 2. Based on interview, staff members do not report unknown bruising or injuries. Interviews reveal that if injury or bruising is noted, there is a reporting procedure. Residents were also interviewed and denied staff handeling them roughly. The resident noted by the Reporting Partthe state’s words, verbatim · CDSS document, Jan 8, 2024 · control 24-AS-20230919144634

Allegation investigated: Staff does not keep facility transportation bus clean Infection Control Procedures are not in place

Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the initial 10 - Day complaint inspection. LPA met with and explained the elements of the allegations with Administrator (AD) Rob Huntley. During the visit, LPA toured the facility as well as the transportation van, conducted interviews and reviewed the facility Infection Control Plan and staff training logs. Based on observation and interview, the transportantion van was not clean. Trash were observed throughout, van interior needs to be cleaned and items properly stored to promote safety. Based on record review, staff have not completed required annual training in the area of Infection Control. The current Infection Control Plan needs to be updated. Five staff training files were reviewed during the visit. See Lic9099-C for continuation of this report Substantiatedthe state’s words, verbatim · CDSS document, Dec 20, 2023 · control 24-AS-20231214111001

Allegation investigated: Staff are not meeting residents incontinence needs

Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a 10-Day initial complaint investigation. LPA met with and discussed the allegation with Administrator (AD) Rob Huntley and Director Of Nursing (DON) Leonel Lopez, LVN. During the visit, LPA conducted interviews and record review. Interviews reveal that Resident (R1) is independent of Activities of Daily Living (ADLs). Per AD and DON, the facility is aware of the change in R1's needs and increased odor which bother other residents in common areas. R1's care plan is in process of being updated though interventions are in process of being implemented. The above 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. There were no citations issued. An exit interview was conducted and a copy of this report was left with AD, whose signature confirms receipt of these documentthe state’s words, verbatim · CDSS document, Nov 30, 2023 · control 24-AS-20231120094937

Report on file with the state — no findings text was published for this visit. The complete document is on the state’s site.