197608482-11-7-2023-28-AS-LHIS-CXJMAF-20231113082614

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 11/07/2023
Date Signed: 11/07/2023 12:48:57 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
06/11/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210611151332

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	SHAUN D. RUSHFORTH		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 185	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Emyrose Lacuesta		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff mismanaged resident's medication.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Angelica Rea conducted another visit to issue the final results of the investigation. LPA met with Director of Health Services, Emyrose Lacuesta and Executive Director, Liyon O'Quinn who assisted with the visit.

Regarding the allegation that faciliy staff mismanaged resident #1's medication, the investigation consisted of interviews with Staff #1 - Staff #4, and Resident #1 - Resident #9. The investigation revealed that Staff #1 went into Resident #1's room on 6/9/21 to administer resident #1's medication. Staff #1 stated she was not familiar with resident #1's medication, but was asked to assist on that day, due to the fact that the charge nurse was running late. Staff #1 stated that she had two medication cups with her when she went into resident #1's room. One of the medication cups was for Resident #1. Resident #1 indicated that she is only supposed to take two pills in the morning, and observed that staff #1 had four pills. Both Staff #1 and resident #1 stated that at some point, one of the pills fell out of one of the medication cups. Staff #1 stated that she was unable to find the pill.

Substantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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 4

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
06/11/2021 and conducted by Evaluator Angelica Rea

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210611151332

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	SHAUN D. RUSHFORTH		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS:	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	10:40 AM
MET WITH:	Emyrose Lacuesta		TIME COMPLETED:	01:10 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not treat resident with dignity and respect.

INVESTIGATION FINDINGS:

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

Regarding the allegation that facility staff did not treat resident with dignity and respect, the investigation consisted of interviews with Staff #1- Staff #4, and Resident's #1 - Resident #9.

Staff interviewed denied the allegation, they stated that facility staff do treat the residents with dignity and respect. Residents interviewed were unable to corroborate the allegation. Eight out of Nine residents interviewed stated that facility staff treat them with dignity and respect.

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.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

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

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20210611151332

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: 11/07/2023

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

Staff #1 stated that she left resident #1's room, without administering any medication, because she wanted to ask the charge nurse to verify the correct medication for resident #1. Both staff #1 and resident #1 stated that resident #1 found the pill that had fallen out of the medication cup, while staff was out of the room. The medication that fell out of the cup, was not one of resident #1's prescribed medications.

Based on record review and interviews conducted, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiencies are being cited according to California Code of Regulations, Title 22 and Health and Safety Code.

An exit interview was conducted with Ms. Lacuesta. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 3 of 4

Control Number 28-AS-20210611151332

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: 11/07/2023

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 11/17/2023 Section Cited CCR 87465(a)(5)	1 2 3 4 5 6 7	(a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (5) Facility staff, except those authorized by law, shall not administer injections, but staff designated by the licensee may assist persons with self-administration as needed.	1 2 3 4 5 6 7	The administrator will ensure that staff who distribute medication to residents are properly trained in assisting with medication administratrion. Administrator will provide an inservice traininig to all staff that administer medication, and will provide proof of training to LPA by POC due date.
	8 9 10 11 12 13 14	This requirement was not being met as evidenced by : staff #1 dropped a medication pill belonging to another resident in resident #1's room. Staff then left the medication in the room. This poses a health and safety 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: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Angelica Rea	TELEPHONE: (323) 980-4929
LICENSING EVALUATOR SIGNATURE:	DATE: 11/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/07/2023

LIC9099 (FAS) - (06/04)

Page: 4 of 4