197608482-11-3-2020-28-AS-MVAO-BX8S4V-20210113123321

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 11/02/2020
Date Signed: 11/03/2020 07:48:02 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 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
04/09/2020 and conducted by Evaluator Renee Arterberry

COMPLAINT CONTROL NUMBER: 28-AS-20200409111220

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	SHAUN D. RUSHFORTH		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 209	DATE:	11/02/2020
		UNANNOUNCED	TIME BEGAN:	12:00 AM
MET WITH:	Manny Ross, assistant-administrator		TIME COMPLETED:	04:30 PM

ALLEGATION(S):

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Staff did not protect resident from financial abuse

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Ren’ee Arterberry initiated a Complaint Follow-Up Visit to investigate the allegation noted above. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures today's complaint investigation was conducted telephonically with Kingsley Manor administrator Mr. Manny Ross. The investigation consisted of the following: on 04/14/2020 LPA Patricia Rivas conducted the initial Complaint Visit and interviewed the administrator. LPA Rivas requested; copies of; Theft and Loss Log, Theft and Loss Policy, Staff Schedule for the week of April 6, 2020/LIC500 and Resident Roster.
During the course of today's visit, at 12:10 PM LPA Arterberry interviewed a resident who shall be referred to as R1. At 12:15 PM the LPA also randomly selected and interviewed a total of six (6) residents and they shall be referred to as, R2, R3, R4 R5, R6 and R7. At 2:20 PM The LPA also randomly selected and interviewed a total of six (6) caregivers and they shall be referred to as; S2, S3, S4, S5, S6 and S7. The administrator shall be referred to as, S1 and was previously interviewed by LPA Patricia Rivas (over the phone). The investigation reveal the following:

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

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-20200409111220

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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 MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 11/02/2020

NARRATIVE

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All residents deny that they were instructed by staff to transfer or withdraw money from their bank account. All residents also deny that money was withdrawn from or transfers made that they did not authorize. In addition, all residents deny being told by other residents that staff instructed them to withdraw or transfer money from their bank accounts. All residents are aware of the theft and loss procedures. All residents deny that unauthorized withdraws were made or unauthorized transfers were made from their bank accounts. In addition, all residents deny being instructed by staff to withdraw or transfer money from bank accounts.

The administrator state that when a resident report personal items to be missing he record it on the Theft and Loss Log and conduct an investigation. The administrator further state that R1 did not notify him nor was he notified by staff that money was missing from R1's bank account.

A review of the Kingsley Manor, Theft and Loss Log does not contain a notation that money in any amount noted. Furthermore, there is no evidence that an internal investigation was conducted by the administrator or any staff member.

The administrator and six caregivers were randomly selected and interviewed; including Licensed Vocational Nurses. Seven residents were also randomly selected and interviewed. The Kingsley Manor Admission Agreement with a special emphasis on the Theft and Loss Section was reviewed. The Theft and Loss Log was also reviewed. Based on the evidence, interviews conducted and documents provided the finding is unsubstantiated. Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the complaint investigation of the allegation is unsubstantiated.

No Deficiencies cited under California Code of Regulations Title 22

A telephonic exit interview was conducted with Assistant Administrator, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Renee Arterberry	TELEPHONE: (323) 981-3342
LICENSING EVALUATOR SIGNATURE:	DATE: 11/02/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2020

LIC9099 (FAS) - (06/04)

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