197608482-3-27-2023-28-AS-RORN-CQSMMP-20230411094417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 03/27/2023
Date Signed: 03/27/2023 11:16:16 AM

Unsubstantiated

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
03/21/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230321084642

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: 181	DATE:	03/27/2023
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Liyon Quinn		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Facility is financially abusing resident while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced initial 10-day complaint investigation regarding the above allegation. LPA discussed the purpose of the visit with Liyon O'Quinn, Executive Director.
The investigation consisted of the following:
LPA reviewed Resident R 1's file and facility submitted Admissions Agreement, Physician's Report and ID page.
LPA interviewed Resident (R1) at 10:20 AM to 10:45 AM.
LPA interviewed Staff (S1- S 3) and Administrator from 9:30 AM to 10:20 AM.
In regards to the allegation Facility is financially abusing resident while in care, based on interviews conducted, file review and information gathered it was revealed by Power of Attorney (POA) who is family member of R 1 that he has withdrawn over $1250 over the last 2 months. Stated that the facility did not do any wrong doing and that R 1 spent the money gambling. Also stated that when money is to be withdrawn for rent the balance has already been withdrawn and POA now has to make up the payments which will take 6

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

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-20230321084642

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: 03/27/2023

NARRATIVE

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months.
Staff interviewed stated R 1 is spending his own money and facility has no access to his funds.
Stated that R 1 has his own ATM card and when facility goes to withdraw monthly rent the account is already overdrawn.
Interview was conducted with Resident R 1 who stated that the facility did not do anything wrong with his money. Said he did not know $1300 would be for rent and that nobody told him. Said that is the only money taken and that he spends his own money. Said the facility does not touch his money and he spends money at different casinos.
Physician's Report dated 08/05/2022 is checked yes in regards to able to manage own cash resources.

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 held with executive director, Liyon O'Quinn. A copy of the report was provided.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2023

LIC9099 (FAS) - (06/04)

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