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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
107206939
Report Date:
08/03/2021
Date Signed:
08/03/2021 03:58:09 PM
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 LIVING
FACILITY NUMBER:
107206939
ADMINISTRATOR:
PAIGE WILLIAMSON
FACILITY TYPE:
740
ADDRESS:
6161 W SPRUCE AVE
TELEPHONE:
(559) 479-4700
CITY:
FRESNO
STATE:
CA
ZIP CODE:
93722
CAPACITY:
128
CENSUS:
DATE:
08/03/2021
TYPE OF VISIT:
Case Management - Other
UNANNOUNCED
TIME BEGAN:
10:46 AM
MET WITH:
Paige Williamson
TIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) obtained a copy of documents from the Resident's (R1) facility file.
SUPERVISOR'S NAME:
Sergiy Pidgirny
TELEPHONE:
(559) 650-7923
LICENSING EVALUATOR NAME:
Katie Brown
TELEPHONE:
(559) 243-8080
LICENSING EVALUATOR SIGNATURE:
DATE:
08/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/03/2021
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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