<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 02/20/2025
Date Signed: 02/20/2025 04:29:01 PM

Document Has Been Signed on 02/20/2025 04:29 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KINGSLEY MANORFACILITY NUMBER:
197608482
ADMINISTRATOR/
DIRECTOR:		LIYON O'QUINNFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY: 299CENSUS: 177DATE:
02/20/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Administrator Liyon O'Quinn and
DOHS Milca Osorio		TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Nune Margaryan conducted Case Management - Incident visit and met with Administrator and DOHS (Director of Health Services). LPA explained the purpose of today's visit and conducted a health & safety check of residents in care.

Unusual Incident report involving the former Resident 1 (R1) was submitted by the facility on 02/10/25. Incident report has indicating that R1's private caregiver was force feeding R1. R1 was passed away on 02/09/25 due to diagnosis End of Stage of Alzerheimers Disease.

During today's visit LPA interviewed DOHS, Kaiser Hospice Social Worker (SW), Family Member 1(FM1). Family Member 2 (FM2) was interviewed on 02/19/25. LPA reviewed R1's file and obtained copies of the following documents:

  • Admission Record
  • Face Sheet
  • Physician's Report
  • Hospice order for R1 about NPO dated 07/09/25.
  • LAPD Officers information / notes.
  • Record of Death

At the time of visit LPA did not observe nor identify signs of neglect, abuse or other immediate health and safety threats.

An exit interview was conducted, and a copy of the report was provided to DOHS Milca Osorio.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1