197608482-2-7-2024-28-AS-RORN-D2H2DR-20240215161845

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 02/07/2024
Date Signed: 02/07/2024 05:01:55 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
02/01/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240201113402

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: 183	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Liyon O'Quinn, Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff are not meeting resident's needs.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Galarza conducted an initial complaint visit to investigate the above allegations. The purpose of the visit was explained to Executive Director Liyon O'Quinn.

The investigation consisted of the following: A physical plant tour of the interior and exterior of the facility was completed, Staff (S1-S6), residents (R1- R 11), and Assisted Living Waiver (ALW) program staff were interviewed. Resident (R1's) file documents were obtained [Face Sheet, Admission Agreement, Pre-Placement Appraisal, Resident Appraisal, Physician Reports [11/21/20 & 1/8/24], MAR [ Jan 2024- Feb. 2024], Service Plan/notes, ALW Individual Service Plan, Resident's Rights, resident roster, shower assignment list, and LIC 500 Personnel Report. Facility does not maintain an inventory of resident's Personal Property and Valuables.

***Narrative continues next page.***

Substantiated

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: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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 5

Control Number 28-AS-20240201113402

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: 02/07/2024

NARRATIVE

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Allegation: Staff are not meeting resident's needs. It is alleged that facility staff are not meeting the needs of resident (R1) because staff are not addressing changes in condition that are causing the resident to have constipation and/or diarrhea, incontinence issues, and self use of over the counter medications. A total of 11 residents were interviewed. One (1) out of 11 residents stated that staff do not meet their care needs. Resident (R1) stated their needs are met and confirmed they require medication management. All staff denied the allegation. However, based on document review the findings indicate that staff are not following facility medication management procedures and physician's orders because R1's Physician's Reports indicate the resident is not able to administer their own medications. LPA observed multiple bins in the tables that contained over the counter medications like Omeprazole, Mylanta, Pepto Bismol, foot creams, Alka Seltzer, that are not part of physician's orders, and there was Mylanta spilled on the side dresser and floor. In addition, R1 has a diabetic wound on the bottom of the foot that requires care. The dressing covering was very dirty and appeared to have not been changed in over 1 week. LPA took pictures of the foot dressing and showed the photos to staff who acknowledged the foot dressing should have been changed. Based on record review and observations, there is sufficient evidence to corroborate the allegation.

Based on interviews conducted and document review, 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. See LIC 9099D.

An exit interview was conducted with Liyon O'Quinn. A copy of the report and appeal rights were issued.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 28-AS-20240201113402

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: 02/07/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/07/2024 Section Cited CCR 87465(e)	1 2 3 4 5 6 7	Incidental Medical and Dental Care. For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician, on a prescription blank, maintained in the residents file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.	1 2 3 4 5 6 7	Staff shall remove all over the counter medications, conduct staff training, and contact MD to obtain physician's orders if applicable, and address foot care . Submit a written POC of how the deficiency was corrected. POC is due tomorrow.
	8 9 10 11 12 13 14	Based on observation, R1 has multiple over the counter medications in the room that are not listed on medication records, and the resident is self-administering without a physician's order. According to the MD report, R1 cannot administer their own medications; this poses an immediate health and safety risk.	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: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 5

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
02/01/2024 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240201113402

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: 183	DATE:	02/07/2024
		UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Liyon O'Quinn, Executive Director		TIME COMPLETED:	05:00 PM

ALLEGATION(S):

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Staff did not safeguard resident's personal belongings.
Staff are harassing resident.

INVESTIGATION FINDINGS:

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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: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

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

LIC9099 (FAS) - (06/04)

Page: 4 of 5

Control Number 28-AS-20240201113402

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: 02/07/2024

NARRATIVE

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Allegation: Staff did not safeguard resident's personal belongings. It was reported that resident (R1) has had their cell phone, tablet, and new clothes stolen by caregiver staff (S4). It was reported that the resident had knives that were removed from the room. According to interviews conducted, the findings indicate that resident (R1) has mental health conditions with periods of confusion and forgetfulness. All staff denied the allegation and stated that they just learned about the alleged missing cell phone yesterday. Staff (S4) denies stealing R1's phone, tablet, and clothing items. It was stated that the resident has asked S4 for assistance in finding the phone in the room. According to S4, the cell phone has been missing for months, and not 3 weeks. Staff (S4) stated that the resident orders many items and keeps cardboard boxes in the room, which are then removed with R1's permission. In regard to the knives that were removed by staff, it was stated that two large knives were removed and returned to a family member because they pose a threat to the resident. All staff deny the allegation. Resident (R1) stated that S4 has not stolen their cell phone. All other residents interviewed also denied the allegation. Resident (R1's) room was inspected and it was observed the resident has an operable land line telephone in their room, but no cell phone was observed. There is insufficient evidence to prove theft and loss of property.

Allegation: Staff are harassing resident. It is alleged that the Director of Resident Services/Staff (S1) has been harassing resident (R1) about bad hygiene, "peeing" on the bed, bowel incontinence on pants/shorts when going to the dining room, and saying the resident is a horrible person that needs to move out." A total of six (6) staff were interviewed, of which all denied harassment of residents or knowledge that S1 has harassed resident (R1). Staff (S1) stated that they addressed hygiene to resident (R1) by trying to encourage the resident to take a shower and comb their hair, but it has always been done in private and in the resident's room. Staff (S1) denied ever asking R1 about bowel movement on their pants, mentioning any stains on R1's pants, or stating to R1 and family that the resident is horrible. Resident (R1) was the only resident that stated S1 harasses the resident. All other residents interviewed stated that staff (S1) treats the residents with respect and is accommodating to residents.

Based upon record review and interviews conducted the findings indicate that, although the allegations may have happened or are valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur, therefore the allegations are Unsubstantiated.

Exit interview was conducted with Liyon O’Quinn. 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: 02/07/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2024

LIC9099 (FAS) - (06/04)

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