197608482-3-23-2023-28-AS-TVAO-CRJMVS-20230505095711

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 03/23/2023
Date Signed: 03/23/2023 03:30:35 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
03/17/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230317102818

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:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Liyon O'Quinn, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility elevators are in disrepair.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cynthia Chan and Tena Herrera conducted a complaint investigation for allegation - Facility elevators are in disrepair. LPAs arrived unannounced and met with Executive Director, Liyon O'Quinn. The purpose of the visit was explained.

The investigation consisted of the following:
LPAs obtained the resident and staff rosters, toured the Leitzell Hall building, and conducted interviews with Staff and Residents.

The investigation revealed the following:
Allegation - Facility elevators are in disrepair. It is alleged that the one of the elevators in the Leitzell Hall (LH) building was not working. Per the Executive Director, one of the elevators was down for a couple of months due to the elevator company trying to find parts to fix it. The building parts are harder to locate due to the age of the elevator. However, the elevator was fixed and is now working as of last Friday.

Substantiated

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: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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 5

Control Number 28-AS-20230317102818

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: 03/23/2023

NARRATIVE

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LPA interviewed 4 Staff and they all acknowledged that the elevator to the right was down for a while, but is now operable. Interviews were held with 5 residents today. 4 out of the 5 residents, who reside in the "LH" building, stated that one of the elevators was down for some time but both are now working. Some stated it took twice as long to go up and down and some did not have any issues with one working elevator. LPAs toured the LH building and observed both elevators working properly. There were no issues with the elevators shaking or signs of them being malfunctioned.

Based on interviews conducted, the preponderance of evidence standard has been met, therefore, the above allegation is found to be SUBSTANTIATED. California Code of Regulations, (Title 22, Division 6 and Chapter 8), are being cited on the attached LIC 9099D.

An exit interview was conducted. A copy of this report, Plan of Correction, and appeal rights were provided to the Executive Director.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20230317102818

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: 03/23/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/30/2023 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 required by:	1 2 3 4 5 6 7	The licensee shall ensure the elevators are working at all times. The POC is due by 3/30/23. *The POC has been cleared as of today due to both elevators were observed working properly.*
	8 9 10 11 12 13 14	Based on interviews, the licensee did not ensure that both elevators in the LH building were working properly which poses a potential health, safety, and personal rights risk to residents 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: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
03/17/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230317102818

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:	03/23/2023
		UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Liyon O'Quinn, Administrator		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Facility does not have heat.

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Cynthia Chan and Tena Herrera conducted a complaint investigation for allegation - Facility does not have heat. LPAs arrived unannounced and met with Executive Director, Liyon O'Quinn. The purpose of the visit was explained.

The investigation consisted of the following:
LPAs obtained the resident and staff rosters, toured the Leitzell Hall building, and conducted interviews with Staff and Resident.

The investigation revealed the following:
Allegation - Facility does not have heat. It is alleged that Leitzell Hall (LH) building does not provide heat in the residents' rooms when they use the heaters. LPA interviewed the Executive Director who stated that the residents' rooms have their own radiator heaters and can control the temperature. She stated that when the resident came to her with the concern of no heat is being produced in the room, she immediately

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: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20230317102818

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: 03/23/2023

NARRATIVE

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had the maintenance staff check on the issue. It is noted that the circuit breaker automatically trips and the staff will need to reset it manually. During the visit today, LPAs interviewed the technician from Powerhouse company who was testing the boiler and circuit breaker. Per the technician, everything is working properly and the boilers are providing steam heat to the rooms. LPA interviewed the facility maintenance staff, who stated that they have been checking the circuit breaker every 3-4 hours and reset it if needed. 5 out of the 5 residents interviewed in the LH building stated their rooms are maintained at a comfortable temperature. Those who use the heater in the room said that it works and provides heat.

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.

An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Executive Director.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 03/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/23/2023

LIC9099 (FAS) - (06/04)

Page: 5 of 5