197608482-7-11-2023-28-AS-EZAA-CTMV3Q-20230711160507

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 07/11/2023
Date Signed: 07/11/2023 04:05:25 PM

Document Has Been Signed on 07/11/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 179	DATE:	07/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Emyrose La Cresta - Director of Health Services		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Erik Zaragoza conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to the Director of Health Services Emyrose La Cresta, and the Administrator Liyon O’Quinn arrived shortly thereafter. There are currently one hundred seventy-nine (179) residents who reside within the facility.

The following 12 (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs.

Infection Control:

· Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility has

Physical Plant/Environment Safety:

· The contains multiple buildings on its campus including the Administration Building, the Dining Hall Building, Lietzell Hall, Margaret Hall, Kingsly Manor Care Center, and the Whitehouse. It is licensed for a capacity of 285 Ambulatory and 14 Non-Ambulatory residents. It consists of five (5) total buildings that house residents, a dining room, a kitchen and multiple private and public restrooms throughout the facility. Most of the buildings that house residents held water temperature readings that were within the 105 – 120 Degrees F range, however the two (2) restrooms within the White House measured at 140 Degrees F and 126 Degrees F for the Resident Husband’s and Wife’s restrooms respectively. The Maintenance Supervisor arrived at the facility and was able to correct the water temperature during the visit and explained that the heat was set too high accidentally. The facility’s main laundry for residents is located in the basement of Lietzell Hall, and the 6^th floor of Lietzell Hall contains the facility’s rooftop patio, movie theater, and main activity room.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

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

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/11/2023 04:05 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/11/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based onobservation, the licensee did not comply with the section cited above in 2 out of 179 residents, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 07/12/2023
	Plan of Correction
1 2 3 4	Administrator is to ensure that water temperature measures within the required 105 F - 120 F at all times within the White House. Administrator cleared the citation during the visit by contacting the Maintenance Supervisor who adjusted the water temperature during the visit and showed proof that it was within the required range to the LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 07/11/2023

NARRATIVE

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· The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility multiple fully charged fire extinguishers in each floor of the resident’s halls in their laundry room.
· Water temperature readings measured between the required 105 - 120 degrees Fahrenheit in most buildings except the White House which was corrected during the visit.
Operational Requirements:
· The Program Design was reviewed.

· Fire clearance was approved by LA County Fire Department for 285 Ambulatory and 14 Non-Ambulatory residents.

· Care and supervision to meet the clients’ needs was observed.
Staffing:

· A total of one hundred and one (101) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training:

· Two (2) staff files were reviewed for criminal background clearance and training.

· Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.
Client Rights/Information:

· Physician orders were reviewed in client files.

Client Records/Incident Reports:

· Nine (9) client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 07/11/2023

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Food Service:

· The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary.

· No restricted Health Care plan required for the clients in the facility.

Incident Medical and Dental:

· All clients have a Needs and Services Plan, and COVID-19 vaccination cards on file.

· Staff training was on file.

LPA was not able to complete the Annual Inspection at this time and will be returning to complete it.

SUPERVISOR'S NAME: David Sicairos	TELEPHONE: (323) 981-3982
LICENSING EVALUATOR NAME: Erik Zaragoza	TELEPHONE: (323) 981-3983
LICENSING EVALUATOR SIGNATURE:	DATE: 07/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/11/2023

LIC809 (FAS) - (06/04)

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