197608482-2-3-2023-28-AS-TVAO-CP2UCL-20230214142806

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:58:49 AM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/31/2020 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200831135015

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: 190	DATE:	02/03/2023
		UNANNOUNCED	TIME BEGAN:	09:13 AM
MET WITH:	Executive Director Liyon O'Quinn		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Facility is not kept free of insects
Facility has bed bugs

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation regarding the above allegation(s). LPA was met by Administrator Liyon O’Quinn and explained the purpose of the visit.

The investigation consisted of the following: LPA requested and obtained a copy of Staff roster, Resident roster, Plan of Operation, Current admission packet, pest control records from 08/01/20 to 02/01/21. LPA Ramirez interviewed Staff 1 – Staff 5 (S1 - S5), and Resident 1 – Resident 4 (R1- R4). LPA Ramirez toured kitchen and dining room during lunch time and 4 resident rooms at 1:55 pm.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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-20200831135015

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 02/03/2023

NARRATIVE

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The investigation revealed the following: regarding the allegations: "Facility has bed bugs,” allegedly bed bugs were found in residents’ bed by pest control on or about 08/31/2020 or 09/01/2020. Four out of five staff interviewed acknowledged seeing bed bugs in the facility. Two out of the four residents interviewed confirmed their accommodation had bed bugs and received treatment for bed bugs. LPA confirmed this through records review of pest control invoices dated 08/06/2020 through 02/01/2021. Per pest control record review, a service date of 08/06/2020, found bed bugs in resident room MH-103. Per pest control record review, a service date of 09/01/2020, found bed bugs in resident rooms AD-217 and AD-219.

For the allegation, “Facility is not kept free of insects.”, allegedly the facility had an infestation of water bugs and roaches. Four out of five staff interviewed acknowledged seeing roaches in the facility. Two out of the four residents interviewed confirmed their accommodation had been treated for roaches. LPA confirmed this through records review of pest control invoices dated 08/06/2020 and 02/01/2021. Per pest control record review, a service date of 09/17/2020, found roaches in resident rooms LH-308 through LH-310.

Based on interviews conducted with facility staff,residents, and records review, the preponderance of evidence standard has been met; therefore, the above-mentioned allegations are found to be SUBSTANTIATED.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. (Refer to LIC 9099D).

Exit interview was conducted with Executive Director Liyon O'Quinn. A copy of the report and appeal rights were provided to Executive Director Liyon O’Quinn

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20200831135015

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/10/2023 Section Cited CCR 87303	1 2 3 4 5 6 7	87303 Maintenance and Operation (a)The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees, and visitors. This requirement is not met as evidence by:	1 2 3 4 5 6 7	1. Provide a written plan to CCL outlining a revised approach to eradicate facility of bed bugs. 2. Inspect all rooms for cleanliness. 3. Provide training to all staff. 4. Submit training topic and staff attendance log to CCL. 5. Submit proof of corrections by POC due date. Facility did provide treatment to rooms affected. Facility has maintained pest control services since 06/23/2020 in an effort to prevent bed bugs and roaches.
	8 9 10 11 12 13 14	Based on interviews conducted, and pest control document review, at least 3 rooms (AD-217, AD-210, MH-103) were under pest control treatment for bed bugs. Per pest control record review, a service date of 09/17/2020, found roaches in resident rooms LH-308 through LH-310. This pose(s) a potiential risk to the health, safety or personal rights of residents in care.	8 9 10 11 12 13 14
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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.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Kimberly Ramirez	TELEPHONE: (323) 981-3970
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC9099 (FAS) - (06/04)

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