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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 12:52:14 PM


Document Has Been Signed on 04/25/2022 12:52 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:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Paige WilliamsonTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct the Annual Infection Control Inspection. LPA met with and explained the purpose of the visit with Administrator (AD) Paige Williamson. LPA entered through the central entry point where Health Screening was conducted, hand sanitizer and infection control postings were observed.

Infection control procedures which were observed or reviewed by LPA include: Daily symptoms screenings (for staff, residents and visitors), testing, visitation requirements, quarantine/isolation procedures, staffing, PPE and daily infection control procedures. Per AD all staff members are fully vaccinated.

LPA toured the facility inside and out. Required postings as well as Covid-19 related signage was observed throughout the facility. Furniture in common and dining areas are spaced to promote distancing. Facility has designated visitation areas available. LPA observed resident medication and 30-day supply of PPE. LPA observed cleaning and disinfecting products. Bathroom sinks are stocked with liquid soap, paper towels, and covered trash cans were observed.

No deficiencies cited during this inspection.

A copy of this report and an exit interview was conducted with the Administrator.


LPA requested the following updated forms by 5/9/22: LIC 308, LIC 309, LIC 500, LIC 610E, LIC 9020, Copy of current Liability Coverage and Administrator’s Certificate.
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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