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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 04/25/2022
Date Signed: 04/25/2022 12:51:17 PM


Document Has Been Signed on 04/25/2022 12:51 PM - It Cannot Be Edited

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: 73DATE:
04/25/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Paige WilliamsonTIME COMPLETED:
11:49 AM
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Licensing Program Analyst Katie Brown (LPA) arrived at the facility unannounced to conduct a Health and Safety Inspection in conjunction with a 10- day complaint visit (Control Number 24-AS-20220422110820). LPA explained the purpose of the visit and the elements of the investigation with Administrator Paige Williamson. Covid Health Screening was conducted upon entering the facility.

During the visit, LPA toured the facility with AD. LPA observed residents socializing in the lobby and throughout the facility. LPA toured resident Apartments in both Assisted Living and Memory Care. The facility was clean, odor free and all walkways were free of obstruction. LPA toured the kitchen and observed perishable and non-perishable food storage, including emergency supply. Resident and public bathrooms are clean, and hand washing signs were observed. LPA toured outside the facility and observed seating areas and delayed egress gates in working order. LPA observed medication rooms and storage. LPA observed residents happily gathering in the dining room for lunch. All staff were observed wearing masks. Hand sanitizer available throughout the facility. Extinguisher dated March 2022.

No deficiencies cited during this Health & Safety Inspection.





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: 04/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/25/2022
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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