197608482-5-7-2024-28-AS-TVAO-D5KT3C-20240524142208

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 05/07/2024
Date Signed: 05/07/2024 10:20:50 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
10/24/2023 and conducted by Evaluator Cynthia D Chan

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20231024160546

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:	05/07/2024
		UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Liyon O'Quinn, Administrator		TIME COMPLETED:	10:00 AM

ALLEGATION(S):

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Questionable death of resident.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Cynthia Chan conducted a subsequent complaint visit to render findings for the allegation of questionable death. LPA met with Administrator, Liyon O'Quinn, and explained the purpose of the visit.

The investigation consisted of the following:

On 10/26/23, LPA Chan conducted a health and safety check and did not observe any immediate concerns. LPA toured the facility and randomly selected 8 rooms to inspect. The hot water temperature in the rooms were measured within the required range. Food supplies of perishable and non-perishable were sufficient. A copy of the staff and resident rosters were obtained. Documents for 5 residents were requested to be emailed to LPA.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (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.

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20231024160546

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 05/07/2024

NARRATIVE

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The complaint was investigated further by the Department of Social Services Investigator Veronica Padilla. During the course of the investigation, Investigator Padilla interviewed the administrator, 12 Staff members, a personal caregiver, a family member, and 2 Residents. Medical records, Emergency Patient Care report, and Medical Examiner case report for Resident #1 (R-1) were gathered and reviewed.

The investigation revealed the following:

Allegation – Questionable death of resident. It has been alleged that Resident #1’s (R-1) death was caused by Staff #1 (S-1) who was neglectful towards the resident. On 10/3/23 around midnight, R-1 was found on the bathroom floor and sustained injuries. R-1 died 4 days later in the hospital. Based on interviews and record review by Investigator Padilla, it was determined that 2 Staff failed to provide supervision for R-1 during their shifts. S-1, who works the overnight shift, did not check on R-1 until staff heard moaning noises coming from the room. S-1 immediately called 911 when R-1 was found on the bathroom floor. Another staff admitted that during the last 4 hours of the shift on 10/2/23, staff did not check on R-1. The approximate day and time in which R-1 fell was unknown since neither staff checked on resident when they were supposed to. Although R-1 fell and sustained injuries, there is no evidence to show a causal link between the failure to conduct timely rounds and the resident’s death. In addition, the Department of Medical Examiner case report ruled the death as an accident.

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.

An exit interview was conducted. A copy of this report along with the appeal rights were provided to the Administrator.

SUPERVISOR'S NAME: Tony Vasallo	TELEPHONE: (323) 981-3977
LICENSING EVALUATOR NAME: Cynthia D Chan	TELEPHONE: (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

LIC9099 (FAS) - (06/04)

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