197608482-5-17-2023-28-AS-LHIS-CT2KGY-20230622075416

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 05/17/2023
Date Signed: 05/17/2023 10:31:03 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
05/04/2023 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230504152112

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: 182	DATE:	05/17/2023
		UNANNOUNCED	TIME BEGAN:	10:14 AM
MET WITH:	Emyrose LaCuesta, Director of Health Services		TIME COMPLETED:	10:35 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff are not preventing resident from being financially abused by another resident.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Galarza conducted a subsequent visit to deliver findings on the above allegation. The purpose of the visit was discussed with Director of Health Services Emyrose LaCuesta.

The investigation consisted of: On 5/9/23, a physical plant tour of the facility common areas was conducted. Sixteen (16) residents, four (4) staff, private caregiver, and family member (F1) were interviewed. The following file documents pertaining to resident (R1) were reviewed and obtained: [Identification and Emergency Information, Resident Appraisal, Physician's Report (2018), Power of Attorney, Service Plan, progress notes, email correspondence notes with R1's family] and resident and staff rosters. Additionally, resident (R2's) file was reviewed and pertinent documents were obtained. On 5/10/23, family member (F2) was interviewed. On 5/11/23, Director of Health Services emailed the pending updated Physician's Report (2/23/23).

***See LIC9099C for continuation of the narrative***

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

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 2

Control Number 28-AS-20230504152112

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: 05/17/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Allegation: "Staff are not preventing resident from being financially abused by another resident." It is alleged that resident (R1's) long-term partner; resident (R2) is financially exploiting the resident because a financial institution was contacted by R2 with a request to transfer specific stock shares owned by R1 to R2. The residents met each other at the facility and have been in a long-term relationship for approximately nine (9) years. During the course of the relationship, R1 has had significant physical and mental decline. Per Physician's Report dated 8/2018, it is noted that resident (R1) had cognitive impairment due to a Dementia diagnosis. Based on document review, resident (R1) has periods of confusion and forgetfulness but is still able to communicate its needs and wants.

Per staff interviews, the facility notified R1's family that there were Power of Attorney changes made in February 2022 by resident (R1) appointing resident (R2) as "agent" to all powers listed on the Power of Attorney form. In November 2022, resident (R1) and resident (R2) got married. Family interviews confirmed that the facility has informed them of pertinent information regarding resident (R1). LPA interviewed resident (R1), and noted the resident was oriented x 3 to person, place, and situation. The resident denied financial abuse by resident (R2). Resident (R2) denied financially abusing resident (R1), and stated that it was a mutual decision to submit for a transfer stock shares with the purpose of financially securing resident (R2's) future. Since R2 does not have recorded Power of Attorney or trading authorization with the financial institution, financial interests have not been transferred as of yet.

A total of 16 residents were interviewed, of which all denied knowledge of financial abuse between residents.
All staff denied the allegation stating that R1 is able to communicate needs and has appointed resident (R2) as primary authorized representative with Power of Attorney powers. Per facility protocol, suspected financial abuse is immediately reported to all corresponding parties. Dementia is a developing neurodegenerative disease with different trajectory in people. Although, resident (R1) has fluctuating cognitive capacity its file did not have a physician capacity declaration or conservatorship. There is insufficient evidence to corroborate the allegation. Therefore, the facility cannot be charged with financial responsibility.

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 Director of Health Services Emyrose LaCuesta. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2023

LIC9099 (FAS) - (06/04)

Page: 2 of 2