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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 107206939
Report Date: 09/21/2022
Date Signed: 09/21/2022 04:16:18 PM

Document Has Been Signed on 09/21/2022 04:16 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: 86DATE:
09/21/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Christopher SmithTIME COMPLETED:
11:12 AM
NARRATIVE
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Licensing Program Analyst (LPA) Katie Brown arrived at the facility unannounced to conduct a Case Management visit. LPA met with and explained the purpose of the visit with Interim Administrator (AD) Christopher Smith.


The purpose of the visit is to address the incident that occurred on 9/14/22 resulting in Resident (R1) going absent without leave (AWOL). The facility submitted a Special Incident Report (SIR) to CCLD on 9/20/22.

During the visit, LPA toured Memory Care inside and out including R1's apartment. LPA conducted interviews and reviewed R1's facility file.

See attached LIC 9099D for citation issued in accordance with California Code of Regulations Title 22, Division 6, Chapter 8, Article 12.






An exit interview was conducted and Plans of Corrections were reviewed and developed. A copy of this report and Appeal Rights were discussed and left with AD, whose signature on this form confirm receipt of these documents
SUPERVISORS NAME: Sergiy Pidgirny
LICENSING EVALUATOR NAME: Katie Brown
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2022
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 09/21/2022 04:16 PM - It Cannot Be Edited


Created By: Katie Brown On 09/21/2022 at 11:16 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: 09/21/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
09/22/2022
Section Cited
CCR
80075(b)(2)

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87705 Care of Persons with Dementia (b) In addition to the requirements as specified in Section 87208, Plan of Operation, the plan of operation shall address the needs of residents with dementia, including: (2) Safety measures to address behaviors such as wandering…..

This requirement was not met as evidenced by:
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Deficiency was cleared during the visit. Staff training is scheduled and in process, R1's Needs & Service Plan has been updated.

Administrator agrees to conduct staff in-service pertaining to AWOL procedures as well as address R1's specific and newly identified care and supervision needs.
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Licensee did not ensure that the needs of R1s known wandering and exit seeking behaviors were met. R1 was able to jump over the facility wall and walk away without facility staff knowing R1's whereabouts.

This poses an immediate health, safety or presonal rights risk to persons in care.
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Proof of in-service will be provided to CCLD via email by 10/28/2022. To be included: Sraff sign in sheet, training materials, updated Needs & Service Plan for R1.

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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: 09/21/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2022


LIC809 (FAS) - (06/04)
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