197608482-6-21-2021-28-AS-MVAO-C4FQM6-20210629121702

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 06/21/2021
Date Signed: 06/21/2021 11:42:54 AM

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
10/15/2020 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20201015160044

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: 194	DATE:	06/21/2021
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Ted Maneerod		TIME COMPLETED:	12:00 PM

ALLEGATION(S):

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Facility has vermin.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent visit to deliver complaint investigation findings. LPA met with Executive Director Ted Maneerod and explained the purpose of the visit.

Investigation consisted of the following: On 10/22/20, LPA conducted a telephone interview with Executive Director Ted Maneerod and requested copies of Staff and Resident Rosters. LPA also conducted a phone interview with Los Angeles County Department of Public Health, Environmental Health Specialist (EHS) Larry Regalado. LPA received two reports from EHS Larry Regalado via email. One report is dated 10/15/20 and the second report is dated 10/17/20. On 10/23/20, LPA received a third report dated 10/23/20 from EHS Larry Regalado via email. On 6/21/21, LPA Gonzalez conducted a tour of facility inside and out including facility kitchen.

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

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 4

Control Number 28-AS-20201015160044

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: 06/21/2021

NARRATIVE

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The investigation revealed the following: In regards to the allegation, Facility has vermin, it is alleged that on 10/15/2020 at about 11 AM it was discovered that the facility had rats in the kitchen and due to that the facility kitchen was shut down for 48 hours. Interview conducted with Executive Director Ted Maneerod revealed that on 10/15/20 LA County Department of Public Health EHS Regalado visited the facility and found evidence of pest droppings in the facility kitchen. Mr. Maneerod stated that due to what EHS Regalado observed the facility kitchen was given a Facility Status grade B with a score of 82. Mr. Maneerod also stated that the facility kitchen was closed down for 48 hours and during that time which ran from 10/15/20 (Dinner) through 10/17/20 (Breakfast), the facility ordered all meals during that time period for facility residents. Mr. Maneerod stated that EHS Regalado cleared the facility on 10/17/20 at approximately 10am. Interview with EHS Larry Regalado revealed that the facility kitchen was closed down for 48 hours due to his observance of dry and fresh rat droppings during his inspection. Mr. Regalado stated that he observed approximately 40 dry and fresh rat droppings on a brick base of a screened wall vent located under a food prep table, one fresh rat dropping (soft to the touch) inside a food/ utensil storage container located on a shelf below the same food prep table, approximately 30 to 40 rat droppings (Dry and Fresh) located on the floor directly beneath the wall vent and below the same prep table mentioned above, one rat dropping and one dead cockroach stuck to a rodent glue trap which was located on the floor under a reach in refrigerator located approximately 4 feet away from the screened wall vent mentioned above and approximately 12 dry and semi-fresh rat droppings located on the top surface of the automatic dish washing machine. Mr. Regalado stated that 15-20 rat droppings were also observed on the floor of the boiler room as well as old dead cockroaches. Mr. Regalado stated that he directed facility staff to remove the rat droppings from the affected areas, and also to wash and sanitize the surfaces and food utensils. Mr. Regalado stated that he directed the facility to discontinue the operation of the food service at once and until the rodent infestation was eliminated. He also stated that facility kitchen health permit was suspended until 10/17/20 at approximately 10:30am when he re-inspected the facility and observed that the rodent infestation was eliminated and all surfaces were clean and had been sanitized. He indicated that facility was able to resume operation of food service at that time.

Based on interviews conducted with Executive Director Ted Maneerod, Los Angeles County Department of Public Health, Environmental Health Specialist (EHS) Larry Regalado and LPA review documents, the preponderance of evidence standard has been met; therefore, the above mentioned allegation is found to be SUBSTANTIATED.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 4 of 4

Control Number 28-AS-20201015160044

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: 06/21/2021

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	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 Ted Maneerod. A copy of the report and appeal rights were provided to Executive Director.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20201015160044

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/21/2021

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 06/22/2021 Section Cited CCR 87555(b)(27)	1 2 3 4 5 6 7	General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. LPA observed 2 rat trap in kitchen area. This requirement was not met as evidenced by: Based on interviews and review of	1 2 3 4 5 6 7	Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	documents that confirmed that facility had an inspection conducted by LA County DPH and during visit the Environmental Health Specialist observed rat droppings and dead cockroaches in different areas of the facility kitchen. Facility kitchen operations were suspended for 48 hrs, which poses an immediate risk of residents in care.	8 9 10 11 12 13 14	Deficiency cleared at time of visit.
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 06/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021

LIC9099 (FAS) - (06/04)

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