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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 01/27/2021
Date Signed: 01/28/2021 09:45:46 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1314 E SHAW AVE
FRESNO, CA 93710
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:
01/27/2021
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:27 AM
MET WITH:Administrator, Paige WilliamsonTIME COMPLETED:
10:44 AM
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Due to Covid-19 pre-cautionary measures, Licensing Program Analyst (LPA) Darius Williams conducted a Healthy and Safety Check with the facility Administrator, Paige Williamson via phone. The Health and Safety Check was completed in conjunction with a complaint; refer to LIC 9099 dated 1/27/2021.

LPA Williams and the Administrator reviewed Covid-19 mitigation procedures, personnel protective equipment, and fall/injury procedures.

No deficiencies were cited.

Exit interview was conducted and a copy of this report was provided to the Administrator via email and an electronic email read receipt confirms receiving this document.
SUPERVISOR'S NAME: Serigy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Darius WilliamsTELEPHONE: 559-243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 01/27/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/27/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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