107206939-9-17-2021-24-AS-KBRN-C6XR6N-20210917124500

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 09/17/2021
Date Signed: 09/17/2021 12:45:34 PM

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 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: 79	DATE:	09/17/2021
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Paige Williamson		TIME COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management Visit. LPA met with and explained the purpose of the visit with Business Office Manager, Gladys Willhite and Administrator, Paige Williamson.

The purpose of the visit is to follow up on the incidents that occurred on 6/17/21 and 8/7/21. Both incidents were reported to CCL by Special Incident Report (SIR).

The incident that occurred on 6/17/21 resulted in Resident (R1) being absent without leave (AWOL) from the facility. LPA reviewed R1's Physicians Report, Milestone Assessment (Needs & Service) and staff In Service documentation. LPA observed window stop in place on R1's window as described in the SIR.

The incident that occurred on 8/7/21 resulted in Resident (R2) and Resident (R3) having a physical altercation. LPA reviewed R2's Physician Report and Milestone Assessment (Needs & Service) which was updated after the incident on 8/22/21. R2 and R3 were roommates at the time. A room change was initiated, they are no longer in the same room.

No deficiencies cited in today's visit
Exit interview was conducted with Administrator

SUPERVISOR'S NAME: Sergiy Pidgirny	TELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie Brown	TELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:	DATE: 09/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/17/2021

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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