197608482-3-7-2023-28-AS-RORN-CPXQHQ-20230315121130

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:41:11 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
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: 185	DATE:	03/07/2023
		UNANNOUNCED	TIME BEGAN:	12:45 PM
MET WITH:	Lyon O'quinn - Executive Director		TIME COMPLETED:	03:00 PM

ALLEGATION(S):

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Resident sustained an injury while in care.
Resident is threatening the safety of other residents.
Staff do not meet qualifications for the job duties they are performing.

INVESTIGATION FINDINGS:

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Licensing Program Analyst(s)(LPA) Mary Flores and Erik Zaragoza 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. On 3/6/23 LPA Flores requested copies of physician's report, needs and care plan for resident #11(R11) and #12(R12).
(CONTINUED ON LIC 9099C)

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: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

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-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: 03/07/2023

NARRATIVE

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On 3/7/23 LPAs requested copies of eviction letter and documentation on eviction process for R12, and notice to all residents.
The investigation revealed the following: Regarding allegation: Resident sustained an injury while in care. It is alleged R11 fell late at night and hit his/her head and bled all over his/her room. Documents review revealed incident report on 4/28/22 R11 was found on the floor with a face laceration, facility send R11 to the hospital for evaluation and was transfer to a Skill Nursing Facility (SNF) after hospitalization. Physician report dated 5/7/22 notes R11 does not have any physical or mental limitations. Medical record dated 4/28/22 notes R11 was seen by a physician for a laceration to his/her face due to an unwitness fall. Per health and wellness notes dated 4/18/22 R11 did not required wellness checks or additional services, and a note was added on 4/18/22 to provide medication assistance. No other notes on change in condition, or notes on previous incidents were found. LPA Flores was unable to interview R11, as R11 passed away on 1/10/23 per death report dated: 1/12/23. Per Executive Director R11 was receiving independent living services and did not required constant checks. Interviews with residents revealed 6 out of 10 residents interview stated staff respond when they need assistance. 3 out of 10 residents stated to not need assistance and are independent and 1 out of 10 residents stated staff did not respond when assistance was needed.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Resident is threatening the safety of other residents. It is alleged R12 leaves the facility and returns intoxicated and has been threatening other residents with physical violence and obscenities. During document review physician's report dated: 12/27/21 for R12 was observed which notes R12 is able to manage care for self. Incident report dated: 4/14/22 notes R12 yelling at staff. Incident report dated: 4/19/22 notes R12 had agressive behaviors towards staff, 911 was called and R12 was taken by Los Angeles Police Department (LAPD). On 3/4/22 R12 was provided a 30 day notice to terminate Resident Agreement due to failure to comply with the general policies of the community. The notice to terminate list 6 incidents between February and April 2022 in which R12 had "problematic behaviors". Facility contacted 911 on 2/27/22, 3/3/22, and 4/19/22 to assist with R12. R12 property was removed from the facility on 6/14/22 after the process of an unlawful detainer file on 4/19/22. A letter to the residents was send out on 4/19/22 in regards to their concerns with R12 to notify them that facility is ensuring the health and safety of the residents.
(CONTINUED ON LIC 9099C)

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (818) 419-8131
LICENSING EVALUATOR NAME: Mary G Flores	TELEPHONE: (323) 981-3965
LICENSING EVALUATOR SIGNATURE:	DATE: 03/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/06/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 3

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: 03/07/2023

NARRATIVE

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Interviews with residents revealed 5 out of 10 residents stated there was a resident that was aggressive, however not physical who is no longer at the facility. 2 out of 10 residents interview stated there are no aggressive residents. 3 out of 10 residents stated not to know anything about other residents. Interviews with staff revealed 5 out of 7 staff stated there was a resident who was aggressive but not physically towards other residents rather to facility's property. 2 out of 7 staff stated they are not familiar with any resident behaving aggressive.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Regarding allegation: Staff do not meet qualifications for the job duties they are performing. It is alleged housekeeping staff are forced to work overtime and cover shifts for the CNAs even though they are not qualified. Interview with Executive Director revealed that housekeeping staff have performed caregiver duties as part of training for those who desire to move positions. This are performed outside staff's shift and performed on over-time and with supervision of a train staff. Housekeeper interview denied performing duties other than duties related to the job during their shift. 7 out of 7 staff stated to have received initial training related to their job duties and additional training after. 10 out 10 residents stated to feel staff are qualified to perform their duties. Documents reviewed show staff obtained initial training in their areas of responsibilities. Additional training was observed for housekeeping staff #5(S5) related to nurse aide duties dated 12/4/21 as part of a 5 day training.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Lyon O'Quinn Executive Director 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: 03/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC9099 (FAS) - (06/04)

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