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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 02/07/2023
Date Signed: 02/07/2023 02:16:48 PM


Document Has Been Signed on 02/07/2023 02:16 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:LIYON O'QUINNFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY:299CENSUS: 183DATE:
02/07/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:35 AM
MET WITH:Emyrose Lacuesta (Director of Health Services)TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Kruz Long conducted an unannounced annual inspection at the facility. Upon arrival, LPA met with Emyrose Lacuesta (Director of Health Services) and explained the purpose of the visit. The facility is licensed to serve: 285 AMBULATORY. 14 NON-AMBULATORY. HOSPICE WAIVER FOR 14. ROOMS 100,101-108,110,112,113,115,117 ARE APPROVED FOR NON-AMBULATORY.

A tour of the facility contains the following buildings: Administration Building, Leitzell Hall, Margaret Hall, Chapel, Holly Cottage (Library/Fitness Center), Dining Hall and Kingsley Manor Care Center.

During today's inspection, LPA observed the following: Facilities maintains in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. Facility is not operating over capacity or beyond any conditions and limitation on the license. No ammunition or firearms on the premises. Facility maintains a comfortable temperature for residents. All outdoor and indoor passageways are free of obstruction. Hot water temperature measured between 105 degrees F and 120 degrees F in each building. The presence of grab bars for each toilet, bathtub and shower used by residents was observed. Showers have non-skid tiles. Beds have the required linen/supplies which include pillowcase, mattress pads, fitted sheet, blanket and bed spreads. Adequate supply of linens are stored in supply room. Facilities have a signal system that operates from each resident’s living unit. Minimum of one week supply of nonperishable foods and 2 days of perishable foods was observed. All readily perishable foods or beverages capable of growth of micro-organisms is stored in covered containers at appropriate temperature. Smoke/Carbon Monoxide detectors are operable in each building. The facility has sufficient and competent staff to provide the services needed to meet resident needs. A first aid kit has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze, first aid manual available for staff use but inaccessible for residents. Staff assisting residents with ADLs have required training. Staff has criminal record clearance. Staff responsible for direct care and supervision have current first aid training. Facility have a disaster and mass casualty plan. A certified administrator is on the premise for a sufficient number of hours to manage and oversee the business operation. Medications is given per the physician’s directions. Centrally stored medicines is kept in a safe and locked place in each building with residents.

No deficiencies were observed during today's visit.
An exit interview was conducted and a copy of this report was provided to Emyrose Lacuesta.
SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Kruz LongTELEPHONE: (323) 383-8117
LICENSING EVALUATOR SIGNATURE:
DATE: 02/07/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/07/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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