197608482-3-1-2024-28-AS-LHIS-D36QXX-20240308113417

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 03/01/2024
Date Signed: 03/01/2024 11:09:22 AM

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
06/13/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220613092610

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: 184	DATE:	03/01/2024
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Liyon O'Quinn, Executive Director		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff pushed resident causing resident to fall.
Staff threatened resident.
Staff providing care to residents under the influence of illegal substance.
Staff does not treat resident with dignity and respect.
Resident caused injury to another resident while in care.
Staff broke resident’s personal belongings.
Unlawful eviction.
Resident’s personal belongings are missing.
Staff made inappropriate comments towards resident.
Staff did not assist resident in a timely manner.

INVESTIGATION FINDINGS:

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

Licensing Program Analyst (LPA) Galarza conducted a subsequent complaint visit to deliver findings on the above allegations. The purpose of the visit was explained to Executive Director Liyon O'Quinn.

The investigation consisted of: On 6/14/2022, A physical plant tour of the interior and exterior was conducted. Former resident (R1's) room 213 was inspected. Staff (S1- S6) and residents (R2- R6) were interviewed. Former resident (R1) was interviewed at a different time. LPA reviewed cell phone video dated April 27, 2022 involving R1. The incident occurred during dinner meal service. The following documents were obtained pertaining to former resident (R1): Face Sheet, Physician Report, Preplacement Appraisal, Appraisal, 30-Day notice, Admission Agreement, Writ of Execution, Police Arrests [3/6, 4/17, 4/19, 4/27, & 6/6/2022, June 14, 2022 Court Order "Receipt For Possession of Real Property", 23 incident reports, (5/31/22), LIC 500 Personnel Report, resident roster.

***Narrative continues next page.***

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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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 8

Control Number 28-AS-20220613092610

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: 03/01/2024

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

Allegation 1: Staff pushed resident causing resident to fall. It is alleged that the facility security guard/staff (S1) pushed resident (R1) hard two times because the resident wanted to close the dining hall, and as a result the resident fell to the carpet floor. Resident (R1) stated that the incident took place on May 11, 2022 and accused staff (S1) of physical injury. However, a total of six (6) staff were interviewed and all denied the allegation. Per staff interviews, the alleged incident occurred on April 27, 2022 at approximately 9:30 AM in the dining room area. Staff stated that R1 threw itself on the floor and started pushing the dining chairs, kicked the glass on the dining room door with a cane and it's legs. Staff (1) stated resident (R1) kicked their knee and accused staff of pushing the resident. Staff (S1) sustained injuries that required emergency room treatment and had to use crutches for 3 days. A total of five (5) residents were interviewed. Four of the residents interviewed were present during the incident, the four residents stated that they did not see the security guard (S1) push the resident. On the contrary, they witnessed R1 screaming and kicking S1's leg shins. Residents stated that S1 told the resident to stop, but never hit the resident. LPA reviewed cell phone video surveillance of the incident. It showed the resident acting aggressively towards staff and residents, and using their cane and legs to damage the main dining room doors. The resident fell because they lost their balance. Based on record review and interviews conducted, there is no evidence to corroborate the allegation.

Allegation 2: Staff threatened resident. It is alleged that the Maintenance Director (S4) and staff (S5) Director of Sales and Marketing threatened resident (R1) by stating they hope the resident falls "down those stairs and kills" themselves, as well as also verbally threatening R1 and taunting the residents. A total of 6 staff were interviewed, of which all denied the allegation. Both staff (S4) and staff (S5) denied the allegation and stated that the resident frequently said horrific words to all staff and verbally abused staff and residents, and despite that all staff always treated R1 professionally. All residents interviewed stated staff treat residents well and reported that R1 is the person that threatens others. Based on incident report review, the findings indicate that R1 verbally and physically threatened and hurt staff and residents on multiple occasions that resulted in arrests. The allegation, has no merit.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 8

Control Number 28-AS-20220613092610

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: 03/01/2024

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

Allegation 3: Staff providing care to residents under the influence of illegal substance. It is alleged that staff were providing residents prescription "speed" and that the facility's security guard sells crystal methamphetamines to staff and outsiders in the parking lot. According to information obtained, the illegal drugs are available for staff if they are tired. It is also alleged at approximately 25 residents had been given prescription methamphetamines at the care center. All residents interviewed denied knowledge of the allegation. One (1) resident reported that R1 asked them if they could get cocaine for the resident. A total of six (6) staff were interviewed and all denied the allegation and stated they have never observed staff to be under the influence. Staff stated that R1 fabricates stories and the alleged staff name referenced in this complaint, is not one of the security guards employed. One (1) staff reported that on a separate occasion R1 accused the Maintenance Director of giving methamphetamines to nursing staff. There is insufficient evidence to corroborate the allegation.

Allegation 4: Staff does not treat resident with dignity and respect. It is alleged that staff do not treat resident (R1) with respect because staff called the resident curse names and most of these conversations/interactions occurred in private. Based on interviews conducted, the findings indicate that resident (R1) often acted in a belligerent and disrespectful manner towards staff. There were multiple incidents between March 2022- May 2022 in which R1 yelled and cursed at residents and staff, as well as incidents were the resident attempted to hit staff. Most the incidents were a result of drunkenness. All staff interviewed denied the allegation, and reported that the resident verbally abused residents and staff. All the residents interviewed stated that R1 would get drunk and act violently towards residents by attempting to hit some residents and saying bad curse words to female residents. Based on file review, records indicate that R1 had history of alcohol intoxication that caused aggressiveness, and behavior problems. There is lack of evidence to support the allegation.

Allegation 5: Resident caused injury to another resident while in care. It is alleged that resident (R5) assaulted resident (R1) by pushing the resident down into the dirt while the residents were smoking in the patio area after R1 referenced a racial slur to R5. It is also alleged that resident (R3) whom was present during the alleged incident, told R1 that if the resident was seen in the neighborhood they would hurt the resident. Resident (R1) stated that R5 was arrested. Per record review, resident (R1's) statement is false. Resident (R1) was arrested five (5) times during the time they resided at the facility for violent acts to others. All staff denied the allegation, and reported that R1 had multiple physical altercations with residents that resulted in physical injury. All residents interviewed stated R1 was a violent person that accused others of causing injuries, but most of the injuries the resident sustained were self inflicted during episodes on alcohol intoxication. There is insufficient evidence to corroborate the allegation.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 8

Control Number 28-AS-20220613092610

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: 03/01/2024

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

Allegation 6: Staff broke resident’s personal belongings. It is alleged that a security guard staff broke two of resident (R1's) CDs and sprayed wine on two of the resident's walls, and then kicked the door and broke the door jambs. According to information provided, the alleged security guard staff expressed remorse the following day and gave R1 $20.00 for the damage caused. There are a total of 6 security guards that work at the facility. All staff interviewed denied the allegation, and stated they had no knowledge of the alleged incident because R1 never reported personal belongings damage. Staff stated that R1's room was a mess and the resident always locked the room after leaving. Residents stated they have not had their belongings stolen or broken, and had no knowledge of R1's alleged issue with personal belongings. Record review, indicates that R1 has episodes of aggressiveness and property destruction.

Allegation 7: Unlawful eviction. It is alleged that resident (R1) was evicted due to an incident involving a walking cane that was considered a deadly weapon. Resident (R1) denied the allegation and stated that they did not assault anybody. According to staff interviews and record review, the findings indicate that resident (R1) was lawfully evicted due to behaviors i.e., vandalism, drinking, verbal and physical abuse to staff and residents. Resident (R1) was arrested five times while living at the facility. The resident was issued an eviction notice on March 4, 2022. The resident did not move out on the date the tenancy terminated. Therefore, the facility had to file court documents. All staff and residents interviewed believe the eviction was lawful because the resident had destructive uncontrolled behaviors posing a health and safety risk to persons in care.

Allegation 8: Resident’s personal belongings are missing. It is alleged that resident (R1's) eyeglasses, slippers, address book, checkbook, polo shirt, watch, 2 bottles of prescription medications, and a wine bottle were missing from the resident's room. Resident (R1) stated that three weeks later the Resident Services Coordinator informed the resident that the items had been turned in to the front desk. Based on interviews conducted, staff reported that when R1 would get drunk they would lose their things. Someone found R1's checkbook in the smoking area and returned it to the front desk, and another time the resident lost their eyeglasses for 3 weeks and they were found in the laundry room. According to staff interviews, when the resident got drunk things were thrown at staff when attempting to clean the room. Staff stated that when the resident moved out none of their personal belongings were removed, and as of 6/14/2022, the resident's belongings had still not been picked up. LPA inspected the room and confirmed the belongings were still in the room. LPA observed the room in disarray with multiple wine bottles and personal belongings on the room and bathroom floor.

SUPERVISOR'S NAME: Lisa Hicks	TELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi Galarza	TELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:	DATE: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 4 of 8

Control Number 28-AS-20220613092610

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: 03/01/2024

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

Allegation 9: Staff made inappropriate comments towards resident. It is alleged that staff made harassing statements and provoked resident (R1) in attempts to get the resident evicted. According to resident (R1), staff verbally abused the resident by calling the resident curse words and convinced many residents that R1 was a threat to their safety. All staff interviewed denied the allegation, and stated no facility staff speak to any residents inappropriately or curse at the resident. They stated they act professionally and courteously towards all residents even those with behavior problems. The residents that were interviewed stated all staff treat them in a courteous and respectful manner and do not address them in a bad way or use foul language

Allegation 10: Staff did not assist resident in a timely manner. It is alleged that staff did not assist resident (R2) in a timely manner after they fell. Resident (R1) heard resident (R2) yelling saying they had fallen, so R1 called the front desk and after 45 minutes of no staff response, R1 decided to call 911 emergency. Resident (R2) denied the allegation and stated they have only pressed the pendant once and staff responded quickly. Per staff interviews and incident report review, there have been no injury incidents involving resident (R2), nor has the resident been transport to the hospital. The majority of residents stated that staff assist within 5-10 minutes after pressing the pendant, but there have been occasions in which it takes longer than that. Staff denied the allegation and stated they assist the residents as soon as possible after receiving the alert on their pager. There is insufficient evidence to corroborate the allegation.

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 conducted with Executive Director 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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 5 of 8

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
06/13/2022 and conducted by Evaluator Noemi Galarza

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20220613092610

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: 184	DATE:	03/01/2024
		UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Liyon O'Quinn, Executive Director		TIME COMPLETED:	11:20 AM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff not responding to residents call button.

INVESTIGATION FINDINGS:

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

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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

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

LIC9099 (FAS) - (06/04)

Page: 6 of 8

Control Number 28-AS-20220613092610

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: 03/01/2024

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

Allegation: Staff not responding to residents call button. It is alleged staff take 45 minutes or longer to respond to the hallway phone calls and pendant calls. Two residents reported that they have fallen and pressed the pendant, but staff did not respond to the pendant alert for over 1 hour. Resident (R4) reported that they pressed the pendant and staff arrived 2 1/2 hours later. As a result, that incident was reported to the Director of Resident Services. Four (4) out of six (6) staff stated that most staff respond within 30 minutes, because the the pendant takes about 5-15 minutes to register on the staff pagers. It was also reported that some residents press the pendant, but staff cannot find them because they are walking around in the facility premises, so it takes a while for staff to find the residents. According to staff interviews, the pendant alert first goes to the nurse assistant, secondly LVN, then supervisor, and finally the executive director. If staff are tied up somewhere not near the resident it can take up to 30 minutes to respond to the call signal. Based on interviews conducted, it was determined that the problem is likely due to the pager system the facility uses. The facility shall utilize an alert system that meets the needs of the residents. There is sufficient evidence to corroborate the allegation.

Based on 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. See LIC 9099D.

An exit interview was conducted with Executive Director 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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 7 of 8

Control Number 28-AS-20220613092610

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: 03/01/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type B 03/08/2024 Section Cited CCR 87303(i)(1)B)	1 2 3 4 5 6 7	Maintenance and Operation. Facilities shall have signal systems which shall meet the following criteria: All facilities licensed for 16 or more and all residential facilities having separate floors or buildings shall have a signal system which shall:Transmit a visual and/or auditory signal to a central staffed location or produce an auditory signal at the living unit loud enough to summon staff.	1 2 3 4 5 6 7	Executive Director agreed to: 1. Submit a written POC by tomorrow. 2. Proof of staff in-service due 3/8/2024. 3. Proof that the entire building's pager/ signal system and pendants were tested and are receiving the page within facility protocols response time.
	8 9 10 11 12 13 14	This requirement was not met evidenced by: Four (4) out of (6) staff stated at times they respond within 30 minutes, because the staff pendants at times take 5-15 minutes to register/summons the call on staff pagers, and then it may take an additional 10 minutes to reach the resident. 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: 03/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/01/2024

LIC9099 (FAS) - (06/04)

Page: 8 of 8