197608482-11-7-2023-28-AS-RORN-CY3SUY-20231130131156

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 11/07/2023
Date Signed: 11/07/2023 01:45:53 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
01/27/2023 and conducted by Evaluator Valeria Maldonado

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20230127133004

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: 185	DATE:	11/07/2023
		UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:	Emyrose LaCuesta- Director of Health Services		TIME COMPLETED:	02:00 PM

ALLEGATION(S):

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Facility will not accept monthly rent payments from resident when resident attempts to pay monthly rent.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) V. Maldonado made an unannounced subsequent visit to the facility for the purpose of concluding the investigation regarding the above-mentioned allegation. LPA Maldonado met with Director of Health Services, Emyrose LaCuesta, and explained the purpose for the visit.

On 02/02/23, LPA Maldonado made an initial complaint visit. During the visit, LPA Maldonado obtained a copy of the resident and staff roster, and the following documents for Resident# 1 (R1): Facesheet, Physician's Report, Pre-Placement Appraisal, Current Appraisal, 30-Day Notice to Pay or Quit for Amounts Due, Collection Letters issued in May, June and July of 2022, and Billing Notices for each month from September 2021-August 2022. LPA also interviewed Staff# 1-4 (S1-S4) and Resident# 1 (R1). Resident# 2 (R2) accompanied R1 to the interview. LPA informed R1 that the interview would be conducted in private; However, R1 informed LPA that R1 wanted R2 to also speak to LPA regarding the complaint. R2 was also interviewed. A telephone interview was also conducted with the facility's legal advisor.
(Report continued on LIC9099-C...)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
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)

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Control Number 28-AS-20230127133004

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

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The investigation revealed the following:
Allegation: Facility will not accept monthly rent payments from resident when resident attempts to pay monthly rent.
It is alleged that R1 has been attempting to make monthly rent payments to the facility since September 2022, due to payments owed, and the facility refuses to accept them. Per staff interviews, (4) of (4) staff state that an Eviction Notice was issued to R1 for non-payment of rent since R1's admission to the facility. (3) of (4) staff state that an unlawful detainer was filed and have been legally advised to not accept any payment from R1. LPA was able to confirm the Unalwful Detainer and the legal advise against accepting payment, per interview with facility's legal advisor. Per interview with R1, it was stated that R1 wanted the facility to obtain the difference of payment due from the Assisted Living Waiver program. However, the program does not assist in paying rent/board and care fees. After review of the documents received, it was discovered that R1 did not make a payment in full by the due date to quit, which prompted the Unlawful Detainer.

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 and a copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Valeria Maldonado	TELEPHONE: 323-981-3342
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)

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