197608482-3-5-2024-28-AS-FFIS-D3S2MH-20240327173107

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 03/05/2024
Date Signed: 03/05/2024 02:32:43 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
02/27/2024 and conducted by Evaluator Jose Villalobos

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240227143259

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: 180	DATE:	03/05/2024
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Executive Director Liyon O'Quinn		TIME COMPLETED:	02:40 PM

ALLEGATION(S):

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Facility staff did not keep the facility free of obstructions.
Facility staff speak inappropriately to resident.
Facility staff do not treat residents with respect and dignity
Facility staff did not safeguard resident's property.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jose Villalobos conducted an initial complaint investigation visit for the allegation(s) above. LPA met with Executive Director Liyon O'Quinn and the purpose of the visit was discussed.

The following was conducted on todays visit: LPA toured the physical plant, Interviewed Staff #1-#6 (S1-S6), Interviewed residents #1-#10 (R1-R10), collected and reviewed copies of documents from R1's file as well as the staff and resident roster. The investigations revealed the following:

In regards to the allegation "Facility staff did not keep the facility free of obstructions" it was alleged that R1 tripped over a cord in their room possibly left by staff. (6) of (6) Staff interviewed denied the allegations. (10) of (10) Residents interviewed could not corroborate the allegation. Interviews state that R1 had an unwitnessed fall in their room on 2/24/24 but was able to get up on their own...
Continued on LIC 9099-C

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

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-20240227143259

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: 03/05/2024

NARRATIVE

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R1 did not inform the staff until the following day and refused to be assessed or go out to the hospital. LPA reviewed a note on file from staff confirming the information. R1 stated to have tripped over the cable of their own heating pad. It was not an item left by staff or placed by her bed by staff. R1 stated no paths were obstructed by the staff. Based on interviews, observations, and file review; 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.

In regards to the allegation "Facility staff speak inappropriately to resident" it was alleged a staff member spoke to R1 in an aggressive tone. (6) of (6) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interview with R1 states that on 2/25/24 a staff member entered their room to provide their meal and spoke to them rudely. LPA was not provided with a name of the staff or what time of the day it occurred. Staff interviewed stated they have never spoken to residents in an aggressive tone or know of any staff to speak to residents in an aggressive tone. Residents interviewed stated that staff are very helpful and do not speak to residents inappropriately. LPA did not observe staff speaking to residents in any inappropriate manner throughout the visit. Based on interviews, observations, and file review; 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.

In regards to the allegation "Facility staff do not treat residents with respect and dignity" it was alleged that staff yell at residents and barge into their rooms. (6) of (6) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Interview with R1 states that on one occasion a staff member bringing meals to residents rooms, barged into R1's room rudely and has yelled at other residents of the facility. Interviews with other residents conducted stated they have not seen staff enter rooms without knocking and have not seen or heard staff yell at residents. Staff interviewed denied that they have or know of other staff to ever yell at residents. Interviews with staff stated that they will always knocked and introduce themselves when going to any residents room. LPA observed staff knocking and introducing themselves before going into residents room throughout the visit. Based on interviews, observations, and file review; 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.

Continued on LIC 9099-C

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20240227143259

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: 03/05/2024

NARRATIVE

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In regards to the allegation "Facility staff did not safeguard resident's property" it was alleged that R1 had a plaque on the wall that is now missing. (6) of (6) Staff interviewed denied the allegation. (9) of (10) Residents interviewed could not corroborate the allegation. Detail provided was that there was a plaque with a copy of the Declaration of Independence inside it that passed down generations in R1's family that is now missing. Staff interviewed stated they have never seen a plaque of that description in R1's room. File review does not show a list of items that the facility would be responsible for, for R1. Residents interviewed stated they have not heard of anyone stealing items from residents in the facility. Based on interviews, observations, and file review; 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 conducted and copy of this report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Jose Villalobos	TELEPHONE: (323) 980-4939
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2024

LIC9099 (FAS) - (06/04)

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