197608482-1-24-2023-28-AS-FFIS-CNP3PF-20230202172528

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 01/24/2023
Date Signed: 01/24/2023 05:21:14 PM

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
12/31/2020 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20201231140851

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: 185	DATE:	01/24/2023
		UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Liyon O'Quinn, Adminstrator		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff failed to return resident's personal belongings
Staff failed to treat residents' with dignity and respect.
Staff engaged in verbal altercation.
Staff failed to meet the residents' needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conduct a subsequent unannounced complaint investigation and addressed the above allegations. LPA conducted an initial virtual complaint investigation on 01/08/21. Today, LPA met with Administrator, Liyon O'Quinn and explained the purpose of today's visit.

Investigation consisted of the following: interviews of staff from Staff #1 (S1) through Staff #8 (S8); interviews of residents from Resident #1 (R1) through Resident#7 (R7); reviewed Resident#1’s record reviews, and a facility tour. LPA obtained copies of the staff and resident rosters; and resident#1 files with relevant information.

The investigation revealed the following:
In regard to allegation: “staff failed to return resident's personal belongings," it was alleged that staff did not return Amazon packages to resident #1 (R1) and charge R1 for packages storage.
(-Continued in LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

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-20201231140851

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: 01/24/2023

NARRATIVE

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Interviewed with resident#1 (R1) revealed staff returned all R1's packages to R1 and no extra charges on storage. All seven (7) residents, including R1, could not corroborate the allegation. Interviewed with staff from Staff#1 (S1) to Staff #8 (S8) revealed staff would return residents' packages to residents. Therefore, interviews revealed staff did not fail to return resident's personal belonging to residents.

In regard to allegation: “staff failed to treat residents' with dignity and respect," it was alleged that staff yelled at R1 and asked residents for Christmas money as staff's Christmas bonuses. Interviewed with R1 revealed staff treated R1 nicely and respectfully, and facility did not ask residents for staff's Christmas money/ bonus. All seven (7) residents, including R1, could not corroborate the allegation. Interviewed with staff from Staff#1 (S1) to Staff #8 (S8) revealed staff would treat residents with respect and did not ask residents for Christmas money. Thus, interviews revealed staff would treat residents with respect and would not ask residents for staff's Christmas money/bonus.

In regard to allegation: “staff engaged in verbal altercation," it was alleged that staff yelled at R1 and R1' husband. Interviewed with R1 revealed that staff did not yell at R1 or R1's husband. All seven (7) residents, including R1, could not corroborate the allegation. Interviewed with staff from Staff#1 (S1) to Staff #8 (S8) revealed staff would not yell at residents or their family members. Therefore, interviews revealed staff did not yell at residents or families.

In regard to allegation: “staff failed to meet the residents' needs," it was alleged that staff did not provide room to store resident's belongings and meet resident’s needs. All seven (7) residents, including R1, could not corroborate the allegation. Interviewed with staff from Staff#1 (S1) to Staff #8 (S8) revealed staff would provide assistance to residents and provide extra storage to residents to meet their needs. Therefore, interviews revealed staff did not fail to meet resident's needs.

Although the allegation may have happened or is valid, there’s not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are UNSUBSTANTIATED.

An exit interview was conducted with administrator. A hard copy of this report was provided to administrator.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2023

LIC9099 (FAS) - (06/04)

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