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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 12/08/2021
Date Signed: 12/10/2021 03:19:43 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 LIVINGFACILITY NUMBER:
107206939
ADMINISTRATOR:PAIGE WILLIAMSONFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 83DATE:
12/08/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Paige WilliamsonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a Case Management visit. LPA met with and explained the purpose of the visit with Administrator (AD) Paige Williamson.

The purpose of the Case Management visit is to follow up on a Special Incident Report (SIR) and SOC 341 submitted to CCLD by the facility on 10/4/21. The incident occurred on 10/3/2021 resulting in an alleged physical altercation between R1 and R2.

LPA reviewed the resident files and interviewed AD about the incident. R1 and R2 share a room and do not with to be separated.




No deficiencies cited during this Case Management visit.
A copy of this report was provided, and an exit interview conducted with Paige Williamson.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 650-7923
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 243-8080
LICENSING EVALUATOR SIGNATURE:

DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021
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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