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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 12/08/2021
Date Signed: 12/08/2021 02:45:10 PM

Document Has Been Signed on 12/08/2021 02:45 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:PAIGE WILLIAMSONFACILITY TYPE:
740
ADDRESS:6161 W SPRUCE AVETELEPHONE:
(559) 479-4700
CITY:FRESNOSTATE: CAZIP CODE:
93722
CAPACITY: 128CENSUS: 83DATE:
12/08/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Paige WilliamsonTIME COMPLETED:
01:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived unannounced at the facility to conduct a Case Management visit. LPA met with and explained the purpose of the visit with Administrator (AD) Paige Williamson.

The purpose of the Case Management visit is to follow up on a Special Incident Reports (SIR) submitted to CCLD on 11/23/2021. SIRs were not submitted to the licensing agency within seven days of the occurrence.

The facility did not submit a SIR to CCLD reporting a fall which occurred on 11/28/21. SIR and Hospice notification provided during this visit.

The facility did not submit a SIR to CCLD reporting an incident which occurred on 9/14/21 resulting in R1 being hospitalized. SIR provided during this visit.

See 809-D for Deficiency


A copy of this report and Appeal Rights were provided and an exit interview was conducted with Paige Williamson.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 12/08/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/08/2021
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 12/08/2021 02:45 PM - It Cannot Be Edited


Created By: Katie Brown On 12/08/2021 at 02:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1314 E SHAW AVE
FRESNO, CA 93710

FACILITY NAME: KINGSTON BAY SENIOR LIVING
FACILITY NUMBER: 107206939

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/08/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/16/2021
Section Cited
CCR
87221(a)(1)

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87211 Reporting Requirements
(a) Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following:
(1) A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case.

This requirement was not met as evidenced by:
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Licensee has agreed to submit a written statement which addresses the facility procedure and plan to report incidents to CCL as required. The statement will include the signatures of those designated to write and submit SIRs. The statement will be provided to CCLD by 12/16/21.
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Licensee did not submit complete Special Incident Reports to to CCLD within 7 days. Incident dates include 11/12/21, 11/13/21, 11/15/21, 11/28/21 and 9/14/21.

This poses a potential health and safety risk to persons in care.
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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 Pidgirny
LICENSING EVALUATOR NAME:Katie Brown
LICENSING EVALUATOR SIGNATURE:
DATE: 12/08/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/08/2021


LIC809 (FAS) - (06/04)
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