197608482-2-7-2023-28-AS-MVAO-CPGTB6-20230228133436

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 02/07/2023
Date Signed: 02/07/2023 03:55:58 PM

Unsubstantiated

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
11/17/2022 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20221117140200

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	LIYON O'QUINN		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 183	DATE:	02/07/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Liyon O'Quinn, Executive Director		TIME COMPLETED:	04:00 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

1. Staff do not provide proper assistance to resident in care.
2. Staff is not mitigating the spread of pests in the facility.
3. Staff are not following COVID-19 protocols to mitigate the spread of the virus.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent visit regarding the allegations listed above. LPA met with Executive Director, Liyon O'Quinn, and explained the purpose of the visit.

On 11/22/22, LPA obtained the staff roster, resident roster, and the Ecolab Pest Control Service reports from September 2022 through November 2022. Interviews were held with the Executive Director and 7 Staff.
During the visit today, LPA toured the facility and interviewed 10 Residents, Pest Control technician, and the Los Angeles County Public Health nurse.

The investigation revealed the following:
Allegation - Staff do not provide proper assistance to resident in care. It was alleged that the staff did not want to help Resident #1 (R-1) move boxes/items and unpack. Per the Executive Director, staff assisted R-1 multiple times in moving boxes in the room and rearranging the room. According to Staff who assisted R-1, accommodations were made to help rearrange or move R-1’s boxes in the room.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
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.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20221117140200

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: 02/07/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

They stated that it took about 2 months since it was based on R-1’s availability. Staff interview indicated that R-1 is independent and does not need much assistance. However, Staff stated they will assist residents when they need it, including independent residents. Interviews were held with 10 Residents in which all of them stated staff will assist and respond to their needs immediately when they push their pendants.

Allegation - Staff is not mitigating the spread of pests in the facility.

According to the Executive Director, the pest control company Ecolab inspector comes out quite frequently to spray for cockroaches and/or bed bugs. When a resident reports any observation of bed bugs or pests, she will address the issue and arrange for the pest control inspector immediately. The staff will also observe for bed bugs as they are cleaning the rooms and changing the sheets. The Staff interviewed have not observed nor received reports of any bed bugs or cockroaches lately. They stated when residents report seeing bed bugs or roaches, the staff will immediately check the room and request for services from the pest control company. LPA interviewed the Ecolab pest control technician who indicated that the facility has a contract to spray the grounds and some rooms for cockroaches and other pests, biweekly. The inspection for bed bugs is separate and provided upon request. The technician also stated that the facility appears to be doing a good job to mitigate the spread of pests. Interviews were held with 10 residents who stated they see the exterminator come spray often but have not seen any bed bugs or cockroaches recently.

Allegation – Staff are not following COVID-19 protocols to mitigate the spread of the virus.

During the visit today, LPA toured the facility and observed signage posted throughout the buildings to promote proper hygiene and social distancing. LPA observed Staff wearing face masks and most of the residents wearing masks while indoors. The Executive Director stated that they have continuously follow the strictest Coronavirus (COVID-19) required/recommended guidance from different agencies. They recommend and remind residents to wear a mask when they leave their rooms. For those who were tested positive for COVID-19, they have residents quarantine in their rooms to prevent exposure to others. Staff interviewed stated that they follow COVID-19 protocols as best as possible. They wear a mask and wash their hands thoroughly. For caregivers who work directly with positive COVID-19 residents, they stated they are trained on donning/doffing PPE supplies. They wear a N95 mask and after leaving the room, they immediately discard the trash bag with the worn PPE items. Staff will remind or redirect residents back to their rooms if they are still in isolation.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
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

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20221117140200

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: 02/07/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

LPA interviewed 10 residents today and majority of them, except for one, feel that the staff are doing a good job in mitigating the spread of COVID-19. Some noted that staff remind the residents to wear a mask but some will refuse. They also stated that the facility was following the guidance to close down the dining hall and activities while they had their outbreak. In addition, LPA interviewed the Los Angeles County of Public Health nurse assigned to the most recent outbreak in November 2022, stated the facility appeared to adhere to the COVID-19 guidance but also provided recommendations to better mitigate the spread.

Although the allegations may have happened or are valid, there is 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 the Executive Director. A copy of this report along with the appeal rights were provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
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

LIC9099 (FAS) - (06/04)

Page: 3 of 3