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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 09/21/2023
Date Signed: 09/21/2023 04:42:09 PM


Document Has Been Signed on 09/21/2023 04:42 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:ROBERT HUNTLEYFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY:128CENSUS: 68DATE:
09/21/2023
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
04:04 PM
MET WITH:Rob HuntleyTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Health & Safety inspection in conjunction with a 10-Day complaint investigation (Control Number 24-AS-20230919144634) LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley.

During the visit, LPA toured the facility with AD. LPA observed residents throughout the facility including participating in a flower arranging activity. LPA observed multiple resident apartments which were found to contain required furnishings and lighting. LPA observed required items in bathrooms which were clean. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPA observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food. Walkways and doorways were free of obstruction. The facility has designated visitation areas available inside and out. Smoke and Carbon Monoxide detectors present and in working order. Fire extinguishers are located throughout the building with service date of 3/27/23.

In room 127, LPA observed MiraLax Powder and Triamcinolone Ointment on the counter along with 2 pills. R1 is independent in medication administration and management but R2 is not. These medications were not locked and inaccessible to R2.

A deficiency is being cited in accordance with California Code of Regulations on the attached LIC 809-D

An exit interview was conducted and Plan of Correction (POC) was developed. A copy of this report and Appeal Rights were provided to AD during the visit.

SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
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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Document Has Been Signed on 09/21/2023 04:42 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2023
Section Cited
CCR
87465(h)(1)(C)

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87465 Incidental Medical and Dental Care (h) The following requirements... (1) Medications shall be centrally stored under the following circumstances: (C) Because of potential dangers... facility and the condition or the habits of other persons in the facility, the medications are determined,… or Department to be a safety hazard to others.
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R1's medications were immediately secured and made inaccessible to R2. AD has agreed to provide a written statement to CCLD which will include the plan for the assessment of and permanant storage of R1's medications. This will be submitted via email to CCLD by POC date.
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This requirement was not met as evidenced by: Licensee did not ensure that medications were inaccessible to R2. R1's medications were observed on the counter of the room shared by R1 and R2. R1's medications were not locked. This poses an immediate health & safety risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2023
LIC809 (FAS) - (06/04)
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