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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 10/07/2025
Date Signed: 10/07/2025 05:27:35 PM

Substantiated


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
07/23/2025 and conducted by Evaluator Luis DeLeon
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250723092255
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: 177DATE:
10/07/2025
UNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Director of Health Services Milca OsorioTIME COMPLETED:
05:15 PM
ALLEGATION(S):
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Staff did not provide adequate supervision to prevent resident from eloping.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint investigation visit to deliver findings for the allegation listed above. LPA met with the Director of Health Services Milca Osorio and explained the reason for today’s visit. Director Osorio stated that Director Liyon O'Quinn was not available for today's visit

During the initial visit on 07/29/2025, LPA De Leon obtained the following documents: Staff and Resident Rosters, admission Agreement, Physician’s Report, Nurse’s notes, Face Sheet, SIRs, and hospital discharge. LPA conducted Interviews with residents and staff.

On today’s visit, LPA toured residents’ common areas and observed no health and safety risks. LPA delivered findings on above allegations.

Report continues on page LIC-809C...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
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 3
Control Number 28-AS-20250723092255
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: 10/07/2025
NARRATIVE
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Regarding allegation: Staff did not provide adequate supervision to prevent residents from eloping. It is alleged that a resident was missing since 07/20/2025. As of the date of submitting the complaint report to CCLD, the resident (R1) had not returned and was missing. It is alleged that R1 had recently shown to be having issues with cognitive decline and had been hospitalized twice. It is alleged that facility should have provided supervision to prevent R1 from eloping.

The investigation revealed that record review indicated the R1 left facility on 07/20/2025 at approximately 11:00 AM. LPA interview with residents revealed that four (4) out of seven (7) residents were aware of a resident missing from the community. However, residents did not personally know R1. Residents became aware of R1 missing from other residents’ comments. LPA interview with staff revealed that six (6) out of six (6) staff were aware of R1 missing. Records reviewed revealed that based on R1’s physicians report dated 04/29/2025, R1 was not able to leave facility unassisted. Staff 1 (S1) stated that R1’s physician report dated 04/29/2025 indicated that R1’s inability to leave facility was because of physical condition and not because of mental disability. S1 provided a physician’s progress note dated 07/22/2025 indicating to the effect of R1’s physical limitation as the reason to not leave the facility unassisted. R1 returned safely to facility on 07/23/2025. On 07/29/2025, R1 was reassessed, and a new physician report was issued indicating R1 risk for elopement. Based upon the investigation, resident and staff interviews, document review, and LPA observations, the licensee did not ensure to follow physicians report to not allow R1 from leaving facility without adequate supervision even for reason of physical condition and not mental.

Based on LPA observations and interviews which were conducted and record reviews, the preponderance of evidence standard has been met, therefore, the above allegations are found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 & Chapter 8, are being cited on the attached LIC-9099D.

Exit interview held with Director of Health Services Milca Osorio. A copy of the report and appeal rights were provided.


SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20250723092255
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/24/2025
Section Cited
CCR
87411(a)
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87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs. In facilities licensed for sixteen or more, sufficient support staff shall be employed to ensure provision of personal assistance and care as required in Section 87608, Postural Supports. Additional staff shall be employed as necessary to perform office work, cooking, house cleaning, laundering, and maintenance of buildings, equipment and grounds. The licensing agency may require any facility to provide additional staff whenever it determines through documentation that the needs of the particular residents, the extent of services provided, or the physical arrangements of the facility require such additional staff for the provision of adequate services.
This requirement is not met as evidenced by:
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Licensee/Administrator agreed to:
1. Adhere to approved Plan of Operation Staffing Plan and Hours.
2. Submit a written plan regarding staffing schedules, and a copy of staff in-service training to prevent eloping.
Licensee shall provide CCLD with plan and training sign by all staff by POC date.
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Based on observation, interview, record review, the licensee did not comply with the section cited above in R1 was able to leave facility unassisted even though R1's physician's report stated that R1 was not to be allowed to go out of the facility, which poses/posed a potential health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 3