197608482-2-9-2023-28-AS-RORN-CPXQHR-20230315121130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 02/09/2023
Date Signed: 02/09/2023 02:23:53 PM

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
04/29/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220429152504

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: 180	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Liyon O'quinn - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility has bed bugs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores conducted an unannounced complaint investigation visit regarding the above allegation(s). LPA Flores met with Liyon O'quinn Administrator and explained the reason for the visit.

The investigation consisted of the following: On 5/5/22 LPA Flores requested copies of resident/staff roster, conducted a tour of the facility with Liyon O'Quinn Administrator of the following rooms #Kingsley Manor 108,106, Margaret Hall #200,201,202,100,102 Administration Building #225,224,329,328,330,331 and Leizetl Hall #107,105,210,211,302,300,307,306,424. LPA requested copies of pest control services for the last 6 months, incident reports for the last month. On 1/9/23 LPA Flores interviewed staff #3,#4,#5,#6,#7 over the phone. On 2/9/23 LPA Flores interviewed administrator/staff #1(S1), #2(S2), and residents #1(R1),#2(R2),#3(R3),#4(R4),#5(R5),#6(R6),#7(R7),#8(R8),#9(R9),#10(R10), and requested copies of incident report for R4, job duties description for housekeepers, and caregivers, and initial training for S4 and S5. A copy of R4's physician's report and physician's order were requested. (CONTINUED ON LIC 9099C)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

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 6

Control Number 28-AS-20220429152504

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: 02/09/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility has bed bugs. It is alleged that rooms #200, 201, and 203 have bed bugs on their clothing, bedding and chairs. Interviews conducted with residents revealed 8 out of 10 residents stated to not have observed or experience bed bugs in their rooms. 2 out of 8 residents stated they did had bed bugs. Interviews with staff revealed 4 out of 7 staff interview stated they have not observed or heard of bed bugs at the facility and 3 out of 7 staff interview stated there were bed bugs at the facility and treatment was provided. During facility's tour on 5/5/22 LPA Flores observed bed bugs in the floor below the bed in room #200. Documents review revealed Ecolab Pest Elim, Div - Customer Service Report dated 3/3/22 identify bed bugs activity in room #328. Pest Control Service - Invoice(s) Customer Service Report for 4/26/22, 4/27/22, and 4/28/22 target pest bed bugs in room #200,201, and 202. Customer Service Report dated 5/5/22 noted bed bug infestation in room #329.

Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. California Code of Regulations, Tittle 22, Division 6 and Chapter 8 are being cited.

Exit interview was conducted with Liyon O'quinn Administrator and a copy of this report, LIC 9099D, and appeal rights was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 6

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
04/29/2022 and conducted by Evaluator Mary G Flores

COMPLAINT CONTROL NUMBER: 28-AS-20220429152504

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: 180	DATE:	02/09/2023
		UNANNOUNCED	TIME BEGAN:	08:24 AM
MET WITH:	Liyon O'quinn - Administrator		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

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Facility is not clean and sanitary at all times.
Resident rooms are malodorous.
Facility is not meeting resident's dietary needs.

INVESTIGATION FINDINGS:

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Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 3 of 6

Control Number 28-AS-20220429152504

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: 02/09/2023

NARRATIVE

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The investigation revealed the following: Regarding allegation: Facility is not clean and sanitary at all times. It is alleged that blood was left all over room #113 until housekeeping discovered it at 11am the next day after resident suffered a fall. Interviews with residents revealed 10 out of 10 residents revealed facility is clean and sanitary at all times and have not experience bodily fluids left on the floor for long periods of time. Interviews with staff revealed 7 out of 7 staff stated that upon request to clean out an area housekeepers ensure area is clean and bodily fluids are not left on the floor. Per Director of Health Services housekeepers have a bodily fluid accessible to any staff and it is used to remove bodily fluids immediately and housekeeping receives a notification to follow up with cleaning. During facility's tour on 5/5/22 and observations on 2/9/23 LPA Flores observed facility was clean, sanitary and free of bodily fluids.
Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED

Regarding allegation: Resident rooms are malodorous. It is alleged resident's room had a pile of dirty diapers in room #123 for weeks and the room smells very bad. Interviews with residents revealed 10 out of 10 residents revealed facility is clean and sanitary at all times. Interviews with staff revealed 7 out of 7 staff stated that housekeepers ensure facility and rooms are clean. During facility's tour on 5/5/22 LPA Flores observed 22 resident rooms, rooms were clean, no odors were noticed, and piles of trash were not observed. On 2/9/23 LPA Flores observed facility's hallways, common areas, and resident rooms and room #123 were free of odors and trash.
Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED

Regarding allegation: Facility is not meeting R4's dietary needs. It is alleged resident has been suffering from constipation for 2 weeks and the nurses will not give prune juice per resident's request. Interviews with 8 out of 10 residents revealed facility staff meet residents' dietary needs 2 out of 10 residents stated facility does not meet residents' dietary needs. Interviews with staff revealed 6 out of 7 staff stated facility follows dietary needs for residents and a dietitian provides services to the facility. 1 out of 7 staff stated not to be familiar with dietary needs. LPA Flores reviewed physician's report for R4 which does not note any dietary needs.
Based on interviews and observation, the preponderance of evidence standard has been met, therefore the above allegation is found to be UNSUBSTANTIATED
Exit interview was conducted with Liyon O'quinn Administrator and a copy of this report was provided.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 6

Control Number 28-AS-20220429152504

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: 02/09/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 02/09/2023 Section Cited CCR 87303(a)	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	Administrator provided LPA Flores a copy of Pest Control Customer Service Report dated: 10/25/22 which notes "no bedbug activity was found during treatment." Deficiency cleared during visit as of 2/9/23.
	8 9 10 11 12 13 14	Based on observation licensee did not ensure facility was free of bed bugs which is a potential health, safety, or personal rights risk to the persons in care.	8 9 10 11 12 13 14
	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: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2023

LIC9099 (FAS) - (06/04)

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