197608482-4-24-2023-28-AS-RORN-CT2UUZ-20230622155423

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 04/24/2023
Date Signed: 04/24/2023 12:05:37 PM

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
04/17/2023 and conducted by Evaluator Glenn Trueman

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230417122733

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: 178	DATE:	04/24/2023
		UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Liyon Quinn		TIME COMPLETED:	12:15 PM

ALLEGATION(S):

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Staff not following resident's dietary needs.

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. Resident and Staff Roster were submitted.
LPA along with Administrator conducted a tour of the dining room and kitchen and checked the food supply.
LPA interviewed Resident's (R1- R 6) at 10:10 AM to 11:00 AM.
LPA interviewed Staff (S1- S 2) and Administrator from 9:30 AM to 10:10 AM.
In regards to the allegation Staff not following resident's dietary needs, based on interviews conducted and information gathered it was revealed in interview with Resident R 1 who stated that there has been no problems in the past week. Stated that the facility does have a special menu just for him and they will also give replacement meals if he feels there is a mistake or wants a different meal. Said that the facility is trying

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: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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-20230417122733

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: 04/24/2023

NARRATIVE

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to improve.
Interviews with Resident's R 2- R 6 who all stated that they always get all 3 meals and a snack and that the food quality is good and well balanced.
All stated that they can request replacement meals and that the dining room staff are professional and very good.
R 3 stated that she does not eat beef and pork, but everything is good and can eat chicken and turkey or other replacements.
R 4 stated that she doesn't eat meats and she can pick what she wants and it is well balanced and the quality is good and the supply is enough,
Interviews with staff who stated that they have created a vegetarian menu just for R 1 and created options that R 1 has circled.
Also stated that R 1 is always able to get a replacement and if he doesn't like they will get him something else.
LPA on tour observed a freezer with all produce, fruits and vegetables. There was nothing canned or frozen.
There was also a large supply of pasta and rices.
Staff also stated that there is also a Don't List with items that R1 does not like.
During kitchen tour LPA observed on the refrigerator a vegetarian menu with choices circled and the name of R 1 listed on it. Also observed was the Don't List .

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.

SUPERVISOR'S NAME: Wei Siew Ho	TELEPHONE: (323) 981-3969
LICENSING EVALUATOR NAME: Glenn Trueman	TELEPHONE: (323) 981-1652
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC9099 (FAS) - (06/04)

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