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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 07/12/2024
Date Signed: 07/12/2024 11:53:03 AM


Document Has Been Signed on 07/12/2024 11:53 AM - 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: DATE:
07/12/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Rob HuntleyTIME COMPLETED:
12:40 PM
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On 7/12/2024 Licensing Program Analyst (LPA) Katie Brown arrived unannounced for a case management - other inspection regarding immediate exclusion of Staff 1 (S1). LPA met with Administrator (AD) Rob Huntley and stated the purpose of the visit.

LPA discussed Staff (S1) with AD. LPA informed Administrator that S1 is excluded and cannot work or be on the premises of the facility and should be disassociated. During the visit, LPA confirmed that S1 was disassociated from the facility on 10/7/2022.

No deficiency was observed.

An exit interview was conducted and a copy of this report was provided to AD, whose signature confirms receipt of this report.
SUPERVISOR'S NAME: Sergiy PidgirnyTELEPHONE: (559) 246-0610
LICENSING EVALUATOR NAME: Katie BrownTELEPHONE: (559) 498-9964
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2024
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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