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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 05/09/2024
Date Signed: 05/09/2024 02:41:48 PM


Document Has Been Signed on 05/09/2024 02:41 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: 93DATE:
05/09/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rob HuntleyTIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a Health & Safety Inspection today in conjunction with opening a complaint (Control Number 24-AS-20240508111233). LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntly and Director of Nursing (DON) Leonel Lopez.

During this visit, LPA toured the facility, observing multiple randomly selected resident apartments. Apartments found to be properly furnished with required lighting. Each resident has a supply of extra towels and linens. LPA observed bathrooms to be clean with grab bars and non-skid shower floors. Hygiene supplies were properly stored and available. Medication rooms were observed during the facility tour.

Residents were observed in Assisted Living as well as Memory Care having lunch, participating in activities or resting in rooms. Common areas are clean and available. Housekeeping carts were found to be locked in hallways while rooms are cleaned. Facility has designated visitation areas available inside and out. Doors and passageways are unobstructed throughout the home including outdoors. Fire Extinguisher service is up to date.

During the facility tour with DON, LPA observed medications not stored appropriately in multiple apartments. A deficiency being cited in accordance with California Code of Regulations on the attached LIC809-D.

A Civil Penalty is being assessed for a Repeat Violation on the attached LIC412FC


An exit interview was conducted and a Plan of Correction was developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirms receipt of these documents.



SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 05/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
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 05/09/2024 02:41 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: 05/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2024
Section Cited
CCR
87465(h)(2)

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87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons.... This requirement was not met as evidenced by:

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AD has agreed to bring in a designated staff member who will conduct a "sweep" of every apartment in the facility and remove any prescription or OTC medications, vitamins or supplements found. The medications will be properly stored.
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Licensee did not ensure that resident medications were centrally stored and locked. LPA observed unsecured medications in the following apartmentts:125, 105, 110, 127, 137, 202, 242 and 231, 313.
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AD will provide a formal written statement by 5pm on poc date that states that the medication "sweep" of the entire facility is complete.

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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: 05/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/09/2024
LIC809 (FAS) - (06/04)
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