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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 06/29/2022
Date Signed: 06/29/2022 12:41:09 PM

Document Has Been Signed on 06/29/2022 12:41 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: DATE:
06/29/2022
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lai SaeteumTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown conducted a Case Management visit. LPA met with and explained the purpose of the visit with Associate Executive Director, Lai Saeteum.


During the visit, LPA toured the facility and observed cleaning supplies under bathroom sinks which were accessible to residents.


The following deficiencies were observed and noted on the attached LIC 809D. All violations that, if not corrected, will have direct and immediate risk to the health, safety or personal rights of clients in care.






A copy of this report including Plan of Correction and Appeal Rights were provided via email to aed@kingstonbayfresno.com and an exit interview was conducted.
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 06/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/29/2022
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 2
Document Has Been Signed on 06/29/2022 12:41 PM - It Cannot Be Edited


Created By: Katie Brown On 06/29/2022 at 11:34 AM
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: 06/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
06/30/2022
Section Cited
CCR
87309(a)(1)

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87309 Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. (1) Storage areas for poisons, and firearms and other dangerous weapons shall be locked.

This requirement was not met as evidenced by:
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During the visit, staff checked and removed disinfectants/cleaning products from under any resident bathroom sinks in Memory Support.

A written statement will be provided to CCLD by 6/30/2022 to include the plan for necessary repairs as well as staff inservice.

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Licensee did not ensure that disinfectants and cleaning solutions were locked and inaccessible to residents. LPA observed cleaning products under bathroom sinks that were unlocked in Memory Support rooms 330, 307 and 301.

This violation poses an immediate health and safety risk to persons in care.
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The facility has agreed to conduct all staff training to address the violation of disinfectants being accessible to residents.
A sign in sheet with the names and signatures of staff who attend along with training materials will be submitted to CCLD on or before 7/11/20

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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: 06/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/29/2022


LIC809 (FAS) - (06/04)
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