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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 08/12/2024
Date Signed: 08/12/2024 04:24:43 PM


Document Has Been Signed on 08/12/2024 04:24 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: 91DATE:
08/12/2024
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Rob HuntleyTIME COMPLETED:
04:45 PM
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management - Health Checks visit in conjunction with a complaint (Control Number 24-AS-20240404121910). LPA met with AD Rob Huntley and Assistant Director of Nursing (ADON) Jordan Valencia.

During this visit, LPA toured the facility with AD, entering and observing resident apartments. LPA obtained copies from Resident (R1's) file. LPA also interviewed ADON.

AD has agreed to provide LPA with August 2024 staff schedule for MC and AL.

There were no citations issued.

An exit interview was conducted and a copy of this report was left with AD, whose signature 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: 08/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/12/2024
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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