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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 06/08/2020
Date Signed: 06/09/2020 08:53:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KINGSLEY MANORFACILITY NUMBER:
197608482
ADMINISTRATOR:SHAUN D. RUSHFORTHFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY:299CENSUS: 210DATE:
06/08/2020
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator, Staff #1TIME COMPLETED:
03:00 PM
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On 6/8/2020, Licensing Program Analyst (LPA) Tao conducted a case management visit for the death of Resident#1 (R1) which occurred on 5/10/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically with the facility administrator, Staff #1 (S1). LPA spoke with Administrator and explained the reason for the tele visit.

LPA conducted an interview with the administrator which consisted of a review of R1’s incident report of the death incident on 5/10/20, R1’s physician report, Nurse progress notes, and pre-placement Appraisal. The LPA requested copies of following documents: R1’s facility notes, R1’s Autopsy report, R1’s Police report, R1’s Death certificate if available, R1’s Emergency Contact Information, R1’s IPP, facility’s LIC 500 roster and clients’ roster to be faxed or mailed to the LPA’s attention at the Regional Office Address listed above by 6/16/2020.

A telephonic exit interview was conducted with the administrator, and a hard copy was provided via emailed for signature.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie TaoTELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:

DATE: 06/09/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/09/2020
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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