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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 05/07/2024
Date Signed: 05/07/2024 10:22:18 AM


Document Has Been Signed on 05/07/2024 10:22 AM - 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 MANORFACILITY NUMBER:
197608482
ADMINISTRATOR:LIYON O'QUINNFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY:299CENSUS: 184DATE:
05/07/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liyon O'Quinn, AdministratorTIME COMPLETED:
10:30 AM
NARRATIVE
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Licensing Program Analyst (LPA) Cynthia Chan conducted a case management visit to issue a deficiency after the department followed up on the incident that occurred on 10/3/23. LPA met with Administrator, Liyon O’Quinn, and explained the reason for this visit.
The Department of Social Services Investigation Branch Investigator Veronica Padilla investigated the death of Resident #1 (R-1). Based on the information gathered, it revealed that Staff #1 (S-1) and Staff #2 (S-2) had been neglectful towards R-1. R-1 was found on the bathroom floor on 10/3/23 and sustained injuries. R-1 died 4 days later in the hospital.
Interviews with S-1 and S-2 revealed that they failed to check on R-1 timely during their shifts. R-1 had a fall and was discovered by S-1 at around midnight on 10/3/23. S-1, who works the overnight shift, did not check on R-1 until the staff heard moaning noises coming from the room. S-1 immediately called 911 and was transferred to the hospital. Another staff (S-2) admitted that during the last 4 hours of the shift on 10/2/23, staff did not check on R-1.
During the investigation, S-1’s personnel file was reviewed. It was discovered that S-1 has a reputation for being neglectful and showed misconduct when the staff was found sleeping on the job and in a resident’s room. On 9/6/23, a staff assigned to work alongside S-1 stated that S-1’s attitude toward a higher authority was rude and unprofessional. On 9/7/23, a staff observed S-1 coming out of R-1’s locked room and appeared to have just woken up. On 12/6/23, 3 staff members witnessed S-1 sleeping on the job. Staff provided written statements to confirm their observations.

Based on record review and interview, it is determined that the facility did not provide proper supervision to the resident in care. A deficiency is being cited on the LIC809D, per the California Code of Regulations, (Title 22, Division 6 and Chapter 8). An immediate Civil Penalty of $500.00 is being issued due to the violation that resulted in the injury of a person in care. Refer to LIC 421IM.
An exit interview was conducted. A copy of this report, appeal rights, and Plan of Corrections were provided to the administrator.
SUPERVISOR'S NAME: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
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 05/07/2024 10:22 AM - 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: 05/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/08/2024
Section Cited
CCR
87411(a)

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87411 Personnel Requirements – General
(a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...
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The licensee shall provide in-service training to all care staff to ensure they meet the needs of residents. The training log will be emailed to LPA by 5/8/24.
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Based on record review and interviews, the licensee did not ensure staff are providing the required needs and supervision to Resident #1 which poses an immediate health, safety, and personal rights risk to residents in care.
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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: Tony VasalloTELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 05/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/07/2024
LIC809 (FAS) - (06/04)
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