197608482-5-16-2022-28-AS-RORN-CHZLYQ-20220906091040

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 05/16/2022
Date Signed: 05/16/2022 03:41:55 PM

Substantiated

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
03/07/2022 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220307130848

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: 197	DATE:	05/16/2022
		UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Liyon O'Quinn		TIME COMPLETED:	03:30 PM

ALLEGATION(S):

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Resident is threatening another resident
Resident is calling another resident names
Resident was able to obtain bleach

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Executive Director Liyon O'Quinn and explained the reason for the visit.

The investigation consisted of: On 3/14/22, LPA Gonzalez collected copies of Staff and Resident Rosters. LPA conducted an interview with Executive Director Liyon O'Quinn and Residents 1-6 (R1-6) and requested/ received pertinent documents related to complaint ninvestigation. On 5/12/22, LPA Gonzalez interviewed Exectutive Director Liyon O'Quinn, Divisional Vice President Randy Herzig, Staff 1-6 (S1-6), Residents 7-19 (R7-19) and conducted a tour of the facility with Executive Director Liyon O'Quinn. LPA toured the facility and observed residents in care in the following facility buildings: Main Building, Leitzell Hall, Administration Building, Margaret Hall, Holly Cottage (Library/Fitness Center), and the Dining hall. LPA also collected copies of Staff and Resident Rosters. LPA additionally interviewed R1's Family Member (R1 FM) and R6's FM (R6 FM).

(See LIC9099C for continuation)

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

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-20220307130848

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: 05/16/2022

NARRATIVE

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The investigation revealed the following: In regards to the allegations, Resident is threatening another resident and Resident is calling another resident names, it is alleged that R4 has physically threatened R6. R4 moved into R6's personal space and made a threatening comment. R6 had to be relocated to another building. It is also alleged that R4 is harassing, screams at, and makes derogatory comments towards R6. Interview with Executive Director Liyon O'Quinn revealed that R6 reported that R4 had insulted them and had made derogatory comments but did not report that they were threatened physically by R4 but did invade R6's personal space by coming very close to their face. Executive Director stated that R4 has been causing a lot of trouble at the facility. She stated that R4 drinks a lot and becomes uncontrollable and destructive. She stated that R4 has been observed to threaten staff and also use derogatory and racial insults towards staff. She stated that many residents have reported their concerns regarding R4 to her but their concerns are based on hearsay. For example, residents feel threatened by R4 due to the outbursts that the resident has had at the facility in which they destroyed the facility lobby and hearing from other residents about their interactions with R4 and residents do not want R4 to continue living in the facility because they fear for their safety. Mrs. Liyon stated that R4 is redirected when they are having such behaviors and the police have been called numerous times. She stated that staff redirect R4 whenever they begin having an episode and stated that the facility has attempted to get R4 evicted but have not been successful. After she received the report from R6 she stated that she relocated R6 so that they felt safe away from R4. Executive Director stated that staff always ensure that all residents are kept safe and out of harms way. Interviews conducted with 3 out of 6 staff revealed that R4 has intimidated facility residents and has invaded residents personal space. 3 out of 6 staff stated that residents are scared due to R4's continuing outburst of rage and destructive behavior. 6 out of 6 staff stated that R4 continuously insults staff and uses racial slurs and derogatory comments toward staff and has also threatened staff with their cane. Interviews with 3 residents revealed that R4 has screamed at them, made derogatory comments and has also harassed them. Interviews conducted with 10 out of 19 residents revealed that they feel that the facility is safe and that staff do their best to keep them safe but R4 is the cause of their concerns and their fear, and expressed that they should not have to feel that way in their home.

For allegation, Resident was able to obtain bleach, it is alleged that R4 tried to pour bleach under the R6's door. It is unknown where R4 got the bleach from. R4 is destructive to property and has been arrested by the police but eventually returned to the facility. Interviews conducted with Executive Director O'Quinn and

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20220307130848

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: 05/16/2022

NARRATIVE

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6 facility staff revealed that R4 did pour bleach at R6's door. Staff stated that the reason for the incident is unknown as well as where R4 got the bleach from. Interview conducted with R6 revealed that R4 poured bleach at their door due to R6 not engaging and participating in flirting with R4 and not wanting to hang out with R4 in their room. R6 also stated that R4 tried to offer them wine and became very upset when R6 declined the offer. R6 stated that they were very scared when R4 became destructive and uncontrollable outside of their door. R4 admitted to throwing bleach on R6's room door and stated that they think they did it due to drinking too much alcohol. R4 stated that they purchased the bleach at a local store and stated that staff did not know that R4 had the bleach. LPA toured the outside of R6's room and observed the damage that was caused when R4 poured the bleach at the doors of rooms 209,and 212..

Based on interviews conducted with facility staff, facility residents, and LPA observations, the preponderance of evidence standard has been met; therefore, the above mentioned allegations are found to be SUBSTANTIATED.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. (Refer to LIC 9099D).

Exit interview was conducted with Executive Director Liyon O'Quinn. A copy of the report and appeal rights were provided to Executive Director.

SUPERVISOR'S NAME: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20220307130848

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/16/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Deficiency Dismissed Type A 05/17/2022 Section Cited CCR 87309(a)	1 2 3 4 5 6 7	Storage Space (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients.	1 2 3 4 5 6 7	Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	This requirement was not met as evidenced by: Based on interviews with residents and facility staff and LPA observations that revealed that R4 poured bleach onto R6's room door, which poses an immediate health and safety risk to the residents in care.	8 9 10 11 12 13 14
Deficiency Dismissed Type B 05/23/2022 Section Cited CCR 87468.1(a)(1)	1 2 3 4 5 6 7	(a) Personal Rights of Residents in All Facilities (1) To be accorded dignity in their personal relationships with staff, residents, and other persons. This requirement was not met as evidenced by:	1 2 3 4 5 6 7	Executive Director to submit written Plan of Correction to ensure the facility is meeting Title 22 Regulation. Executive Director to submit a faxed or mailed copy of POC by due date.
	8 9 10 11 12 13 14	Based on interviews with residents and facility staff that revealed that R4 has screamed at, intimidated and harassed facility resident 6, which a potential risk to residents in care.	8 9 10 11 12 13 14

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: Stefanie Coronel	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3973
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2022

LIC9099 (FAS) - (06/04)

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