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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 07/26/2023
Date Signed: 07/26/2023 04:29:19 PM


Document Has Been Signed on 07/26/2023 04:29 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: 74DATE:
07/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:48 AM
MET WITH:Rob HuntleyTIME COMPLETED:
04:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the purpose of the visit with Administrator Rob Huntley (AD) and Director of Nursing Leo Lopez (DON).

During this visit, LPA toured the facility inside & out. Resident apartments contained required furnishings and lighting. LPA observed required items in bathrooms with hot water measuring 107 degrees F. Resident hygiene supplies were properly stored and available. The kitchen was observed to be clean, in good repair with necessary items and appliances. LPAs observed required food supply and paper products. Knives, cleaning/disinfecting supplies and chemicals are locked and stored separate from food and menus posted. Medications are centrally stored and locked, a medication audit was conducted. First aid kits contain required items. Facility has designated visitation areas. An activity calendar was posted. Outside of the facility toured. LPA observed a delayed egress gate from the Memory Care garden. Doors and passageways are unobstructed throughout the facility including outdoors. Fire Extinguishers dated 3/27/2023. Smoke and Carbon Monoxide detectors present and in working order. LPA conducted resident and staff file reviews and interviews. Administrator certification expiration 5/31/24. LPA reviewed Emergency Disaster Plan and Liability coverage during the inspection.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D.

An exit interview was conducted and 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.
LPA requested the following updated forms faxed to CCLD by 8/9/23: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Surety Bond (Lic402), Personnel Report (LIC 500), Client Roster (LIC 9020)
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
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 07/26/2023 04:29 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: 07/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.696(a)(1)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following: (1) Four hours of training on the care, supervision, and special needs of those residents, prior to providing direct care to residents. The facility may utilize various methods of instruction, including, but not limited to, preceptorship, mentoring, and other forms of observation and demonstration. The orientation time shall be exclusive of any administrative instruction.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview andrecord review, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. File reviews were conducted for 3 staff. Facility was not able to provide evidence of all required initial or annual training.
POC Due Date: 08/09/2023
Plan of Correction
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AD has agreed to conduct an audit of all staff training documentation. A written statement will be submitted to CCLD which will include a description of the audit, the procedure and timeline that the staff training will be completed. A copy of a training "log" will be included. This will be submitted by the POC date.
Type B
Section Cited
CCR
87506(a)
87506 Resident Records (a)The licensee shall ensure that a separate, complete, and current record is maintained for each resident in the facility or in a central administrative location readily available to facility staff and to licensing agency staff.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care. Record review revealed that required documents are not included in resident files and not all documents are complete.
POC Due Date: 08/09/2023
Plan of Correction
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AD has agreed to conduct an audit of resident files. A written statement will be submitted to CCLD which will include a description of the audit, the procedure and timeline that resident files will be completed. A copy of a "check list" will be included. This will be submitted by the POC date.
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: 07/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/26/2023
LIC809 (FAS) - (06/04)
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