197608482-7-29-2025-28-AS-FFIS-DMHTSF-20251016145902

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 07/29/2025
Date Signed: 07/29/2025 05:24:26 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/21/2025 and conducted by Evaluator Luis DeLeon

COMPLAINT CONTROL NUMBER: 28-AS-20250721131320

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	LIYON O'QUINN		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 172	DATE:	07/29/2025
		UNANNOUNCED	TIME BEGAN:	08:10 AM
MET WITH:	Director Liyon O'Quinn		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Facility is charging resident for services not rendered

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Luis De Leon conducted an unannounced complaint investigation visit for the allegation listed above. LPA met with the Director Liyon O'Quinn and explained the reason for the visit.
The investigation consisted of the following: On today’s visit, LPA De Leon obtained the following documents: Admission Agreement, Physician’s Report, Pre-Admission Appraisal, re-appraisal, Incidents Reports (SIRs), Nurse notes, Health and Wellness Review, and Face Sheet. LPA toured resident's common areas and observed no health and safety risks,
Regarding allegation: Facility is charging residents for services not rendered. It is alleged that the facility did not inform R1’s responsible party of additional monthly fee and that R1’s responsible party did not consent to the additional services. It is alleged that the additional fee is not listed in R1's admissions agreement. R1’s responsible party learned of the additional fee in April 2025 when Director Ms. Liyon gave R1’s responsible party a bill for unpaid fees. R1’s responsible party stated that R1 doesn't need additional care and R1 is not getting service that are being charged.
Report continues with page 9099C...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250721131320

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 07/29/2025

NARRATIVE

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The investigation revealed that R1 is self-responsible and it is able to manage own cash resources. The investigations revealed that seven (7) out of eight (8) residents denied that allegation above and that residents do not know anyone who is being charged for services not received. During R1 interview, LPA introduced himself at start of interview, but towards the end of interview, LPA had to re-introduce himself after R1 asked who LPA was. R1 was unable to answer questions from LPA and directed LPA to speak with family. Five (5) out of eight (8) staff denied knowing or being involved in the decision and process to determine rate increases. One staff member stated to be aware of rate increase for R1 but does not get involved in the process to increase rates to residents. Two staff described the process to re-assess R1 health condition which resulted in a rate increase for additional services. After an incident with R1’s eloping from the facility on 8/29/2024, the facility reassessed R1’s health condition. On 9/1/2024, the facility identified the risk of eloping which resulted in additional service to prevent R1’s from eloping. R1 signed off rate increases form which identified the effective date of 9/1/2024. Facility added service to do frequent wellness check and monitoring bracelet to alert staff when a resident is attempting to exit the facility. Facility Staff contacted R1’s primary doctor who requested R1 to visit the doctor’s office. Director Liyon O’Quinn requested R1’s family to set up appointment with R1’s primary care doctor. The facility has been requesting the latest physician report since 9/9/2024. R1’s family assists with R1’s medical appointments and transportation. On July 24, 2025, R1’s family stated via email that facility will get the latest physician’s report as soon as the doctor provides it to the family. Based upon the investigation, client and staff interviews, document review, and LPA observations, the residents is receiving the services as identified by re-assessment to prevent resident from eloping.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview held with Director Liyon O'Quinn. A copy of the report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2025

LIC9099 (FAS) - (06/04)

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