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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 11/16/2022
Date Signed: 11/16/2022 11:38:48 AM

Unsubstantiated


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
11/07/2022 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20221107092001
FACILITY NAME:KINGSLEY MANORFACILITY NUMBER:
197608482
ADMINISTRATOR:LIYON O'QUINNFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY:299CENSUS: 191DATE:
11/16/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Liyon QuinnTIME COMPLETED:
11:45 AM
ALLEGATION(S):
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Staff are not meeting residents showering needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced initial 10-day complaint investigation regarding the above allegation. LPA discussed the purpose of the visit with Liyon O'Quinn, Executive Director.

The investigation consisted of the following:
LPA reviewed Admissions Agreement and Shower schedule for Resident (R1).
LPA toured Resident (R1's) Room 100 and interviewed Resident (R1) at 10:30 AM to 11:00 AM
LPA interviewed Staff (S1) and Administrator from 10:00 AM to 10:30 AM.
In regards to the allegation Staff are not meeting residents showering needs, based on interviews conducted and information gathered Staff interviewed stated that facility staff assisted Resident (R1) with all showering needs on 11/13/2022 and have the next shower with assisting R1 to be completed on 11/20/2022.
Staff stated that it is R1's preference to be showered 1x a week on Sunday's.
Staff stated that a meeting is scheduled for 11/17/2022 with R1, family member of R1, Social Worker of R1
Unsubstantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 28-AS-20221107092001
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: 11/16/2022
NARRATIVE
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and Ombudsman.
Interview conducted with R1 who confirmed that yes she did receive assistance with all her showering needs by CNA staff from facility on 11/13/2022.
Also confirmed meeting to be conducted on 11/17/2022 .
Stated that she prefers 1x a week showering assistance and confirmed Home Health assisted on 11/06/2022.

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 allegation is UNSUBSTANTIATED.

Exit interview held with executive director, Liyon O'Quinn. A copy of the report was provided.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn TruemanTELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2