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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 07/02/2024
Date Signed: 07/02/2024 03:59:18 PM

Substantiated


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
06/25/2024 and conducted by Evaluator Nune Margaryan
COMPLAINT CONTROL NUMBER: 28-AS-20240625090311
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: 187DATE:
07/02/2024
UNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Lyion O'Quinn / Administrator TIME COMPLETED:
03:55 PM
ALLEGATION(S):
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Unlawful eviction.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Nune Margaryan conducted unannounced initial visit to facility to investigate the above allegation. LPA met with Administrator Liyon O'Quinn and explained the purpose of visit.

During today's visit LPA obtained copies of staff and residents roster. Interviews conducted with Administrator, Staff #1 - Staff #2 (S#1 - S#2) and Resident #2 -Resident #4 (R #2 - R #4). LPA also obtained copies of the following documents in reference to Resident #1: Admission Agreement, Physician report, Preplacement Appraisal Information, SIR dated 06/14/24.

Continue 9099C
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
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 3
Control Number 28-AS-20240625090311
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: 07/02/2024
NARRATIVE
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Regarding allegation: Unlawful eviction. It was alleged that R#1 was not allowed to return to the facility after was discharged from the hospital on 06/18/24. Kaiser staff and FM were told by unknown facility staff that R1 would not be allowed to return.

Interviewed Administrator denied the allegation. Administrator stated that on 06/14/24 R1 was sent to Kaiser to be evaluated. R1 was placed on 72 hour hold at the hospital and was discharged on 6/18/2024. Interviewed S1 stated that they spoke with R1's Family Member (FM) and told FM that R1 needs high level of care and supervision because of R1's behavior. Interviewed Administrator and S#1 stated that they were in communication with R1's FM and discussed concern regarding R1 returning to the community with the fact they cannot provide one to one supervision for R1 with R1's behavior. Interviewed FM indicated that they were told by facility staff that facility will not be able to take R1 back to the facility due to R1's behavior. FM was told by S#1 that R1 needs high level of care and supervision, and the facility will not be able to meet R1's needs, and they are not accepting R1 back to the facility. Interviewed S#2 stated that because of R1 behavior S#2 called 911 on 06/14/24 and R#1 transported to the Kaiser for evaluation. S#2 stated that R#1 didn't came back from the hospital. S#2 stated doesn't have any discharge information or not accepting R#1 back to the facility. Interviewed R#2, R#3 and R#4 stated that they never had any issues or problems coming back to the facility after hospitalization.


Due to the fact the staff refused to accept Resident #1 back to the facility after being discharge on 06/18/24 is considered an unlawful eviction. A review of the R1's file revealed no indication that R1 required a higher level of care. LPA did not observe any documentation of giving resident a 30-day notice of removal from the facility.

Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC9099D.



An exit interview was conducted with Liyon O'Quinn. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 28-AS-20240625090311
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: 07/02/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/09/2024
Section Cited
CCR
87224(a)
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87224 Eviction Procedures (a)The licensee may evict a resident for one or more of the reasons listed in Section 87224(a)(1) through (5). Thirty (30) days written notice to the resident is required except as otherwise specified in paragraph...
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Administrator will review Title 22 Regulations, Section 87224 on Eviction Procedures, and submit a written statement to CCL ensuring that he/she understands and will comply with Title 22 Regulations pursuant to this section by the POC due date.
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This requirement is not met as evidenced by: Based on LPA interviews and record review, Facility / administrator refusal to accept R1 back to the facility upon discharge from hospital and not providing R1 with the 30 day eviction notice which poses a potential health, safety or personal rights risk to the 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: Wei Siew HoTELEPHONE: (323) 981-3378
LICENSING EVALUATOR NAME: Nune MargaryanTELEPHONE: 323-981-3378
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC9099 (FAS) - (06/04)
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