<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 06/11/2024
Date Signed: 06/13/2024 03:22:16 PM


Document Has Been Signed on 06/13/2024 03:22 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: 82DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Rob HuntleyTIME COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Katie Brown arrived unannounced to conduct the Annual Inspection. LPA met with and explained the reason for the visit with Administrator (AD) Rob Huntley.

During this visit, LPA toured the facility inside & out. Resident apartments contained required furnishings and lighting. The bathrooms were found to be clean and in good repair with faucets delivering hot water within required temperature. LPA observed required hygiene items, towels, extra bedding, and linens which were stored and available for use. The kitchen was clean, with necessary items and appliances. LPA observed required food supply and paper product storage. Cleaning/disinfecting supplies, knives and sharps are inaccessible to residents and stored separate from food. Medications are locked and centrally stored in medication carts. Medication rooms were locked when not in use. Common and activity areas were clean and occupied by residents throughout. Snack and water stations were available and observed to be well maintained. There are visitation areas available inside and out. Doors and passageways are unobstructed throughout the facility. The Fire extinguishers were 3/28/24 by Midstate Fire Co. A fire inspection was conducted by Fresno fire on 4/11/24. LPA conducted staff and resident file reviews.

Deficiencies are being cited in accordance with California Code of Regulations on the attached LIC 809-D in the areas of: Administrator - Qualifications and Duties, Oxygen Administration, Hospice Care and Resident Records.



An exit interview was conducted and Plan of Correction (POC) developed. A copy of this report was signed by AD and Appeal Rights were provided.
LPA requested the following updated forms faxed to CCLD by 7/11/2024: Designation of Facility Responsibility (Lic308), Administrative Organization (Lic309), Affidavit Regarding Client/Resident Cash Resources (LIC 400), Emergency Disaster Plan (LIC610E), Client Roster (LIC 9020), Proof of current Liability Coverage and Infection Control Plan.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 06/13/2024 03:22 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: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87633(d)
Hospice Care for Terminally Ill Residents
(d) The licensee shall ensure that the hospice care plan is current, accurately matches the services actually being provided, and that the client's care needs are being met at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
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. Residents R1 and R3 do not have a current (certification period) Hospice Plan of Care maintained in their files.
POC Due Date: 07/11/2024
Plan of Correction
1
2
3
4
AD has agreed to obtain the previous and current hospice plans of care and place in resident files. Additionally, AD will submit a written statement that the requirements have been reviewed with the appropriate staff to ensure records are obtained from the hospice agencies and maintained as required. This will be submitted to CCLD by POC date.
Type B
Section Cited
CCR
87458(b)(1)
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious or contagious diseases or other medical conditions which would preclude care of the person by the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and 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. Resident (R4) Physician Report (PR) has not been updated as required. R4 is also Diabetic. The PR states that R4 cannot Administer Glucose testing or insulin injections. R4 has orders for both.
POC Due Date: 07/11/2024
Plan of Correction
1
2
3
4
AD has agreed to obtain a new PR for R4. The PR along with a written statement that the appropriate staff have been inserviced on Medical Assessment requirements. The statement will include a summary of the inservice including documentation of the trainer and which staff attended. This will be submitted to CCLD by 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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 06/13/2024 03:22 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: 06/11/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87405(a)
87405 Administrator - Qualifications and Duties (a) All facilities shall have a qualified and currently certified administrator. The licensee and the administrator may be one and the same person.....

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on interview and 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. AD's Administrator Certification is not current. The certificate expired 5/31/24. Required renewal documents has not been submitted for recertification.
POC Due Date: 07/11/2024
Plan of Correction
1
2
3
4
AD has agreed that within 30 days (POC date), the facility will have submitted an update in writing to CCLD with the status of the Administrator of the facility. Proof of recertification documents submission will also be provided bu the POC date.
Type B
Section Cited
CCR
87618(a)(1)
87618 Oxygen Administration - Gas and Liquid (a) Except as specified in Section 87611(a), the licensee shall be permitted to accept or retain a resident who requires the use of oxygen gas administration under the following circumstances: (1) If the resident is mentally and physically capable of operating the equipment, is able to determine his/her need for oxygen, and is able to administer it him/herself.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on [(observation and 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. Resident (R2) stated to LPA and AD to be having trouble breathing. The oxygen was on and the tubing was on the floor. R2 thought the oxygen was off. Physician Report states R2 cannot self administer Oxygen. R2 resides in memory care.
POC Due Date: 07/11/2024
Plan of Correction
1
2
3
4
AD has agreed to a reassessment of R2 including an updated Physician's Report. The updated care plan and Physician's report will be submitted to CCL for review by 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: 06/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/11/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3