197608482-8-2-2024-28-AS-SVAD-D7RTSU-20240802145943

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 08/02/2024
Date Signed: 08/02/2024 02:59:51 PM

Document Has Been Signed on 08/02/2024 02:59 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

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: 199	DATE:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Milca Osorio, Director of Health Services		TIME COMPLETED:	03:15 PM

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	Licensing Program Analyst (LPA) S Vaid conducted an unannounced Required 1 year visit using the full Care Compliance and Regulatory Enforcement (CARE) Tools. LPA explained the purpose of the visit to the Director of Health Services Milca Osorio, and the Assisted Living Supervisor Salimatou Krubally arrived shortly thereafter. There are currently one hundred ninety-nine (199) residents who currently reside within the facility. The facility is licensed to serve: 285 ambulatory, 14 non-ambulatory, hospice waiver for 14. Rooms 100,101-108,110,112,113,115,117 are approved for non-ambulatory. LPA toured the physical plant and environment with Supervisor Krubally and Health Services Director Osorio. The tour of the facility contains the following buildings: Administration Building, Leitzell Hall, Margaret Hall, Chapel, Holly Cottage (Library/Fitness Center), Dining Hall and Kingsley Manor Care Center. The following (CARE) tool domains were observed and reviewed: Infection Control, Physical Plant/Environment Safety, Operational Requirements, Staffing, Personnel Records/Staff Training, Resident Rights/Information, Resident Records/Incident Reports, Food Service, Planned Activities, Incident Medical and Dental, Disaster Preparedness, and Residents with Special Health Needs. Infection Control: Infection control practices and Personal Protective Equipment (PPEs) were observed. Facility has large supply of protective equipment. Physical Plant/Environment Safety: The contains multiple buildings on its campus including the Administration Building, the Dining Hall Building, Lietzell Hall, Margaret Hall, Kingsley Manor Care Center, and the Whitehouse. Continued on 809 C.....

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 08/02/2024

NARRATIVE

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It is licensed for a capacity of 285 Ambulatory and 14 Non-Ambulatory residents. It consists of five (5) total buildings that house residents, a dining room, a kitchen and multiple private and public restrooms throughout the facility. Most of the buildings that house residents held water temperature readings that were within the 105 – 120 Degrees F range. The facility’s main laundry for residents is located in the basement of Lietzell Hall, and the 6th floor of Lietzell Hall contains the facility’s rooftop patio, movie theater, and main activity room. The interior and exterior physical plant was inspected. Exit doors are free of any obstruction and there are no pools or large bodies of water. The facility multiple fully charged fire extinguishers in each floor of the resident’s halls in their laundry room. Water temperature readings measured between the required 105 - 120 degrees Fahrenheit in all buildings that were toured.

Operational Requirements: The Program Design was reviewed. Fire clearance was approved by LA County Fire Department for 285 Ambulatory and 14 Non-Ambulatory residents. Care and supervision to meet the clients’ needs was observed.

Staffing: A total of one hundred and one (101) full-time staff members provide care and supervision to the clients.

Personnel Records/Staff Training: Eight (8) random staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Client Rights/Information: Physician orders were reviewed in client files.

Client Records/Incident Reports: Eight (8) random client files were reviewed containing admission agreements, Physician's Report, medical/functional assessments, Needs and Services Plans, TB clearance, Appraisal/Needs and Services Plan, personal rights, medical consent, and medication records were reviewed.

Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. No restricted Health Care plan required for the clients in the facility.
Continued on 809C......

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 08/02/2024

NARRATIVE

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Personnel Records/Staff Training: Facility Administrator Liyon O’Quinn certificate is active and effective through 10/11/2024. Eight (8) random staff files were reviewed for criminal background clearance and training. Personnel records have health/TB screenings, CPI training, certifications, and 1st Aid/CPR training.

Health Related Services: Clients are assisted with self-administration of prescription and non-prescription medications. Eight (8) random centrally stored resident medication records were reviewed. Centrally stored medications are kept in a safe and locked place not accessible to clients in care. Medications are given according to Physician directions.

Disaster Preparedness, and Emergency Intervention: A posted Emergency Disaster Plan LIC 610D containing emergency evacuation information was observed. An emergency drill is conducted each quarter and was last conducted on 06/11/24 during various shifts , and Fire Alarms were check on 5/14/2023, fire alarms were updated to new systems in 04/2024. Inspection testing the new fire alarms were tested and inspected by the Los Angeles Fire Department in early May 2024. Outside vendor will perform the fire alarm checks and is scheduled for the coming weeks.

No deficiencies were observed during today's visit.

An exit interview was conducted and a copy of this report was provided to Salimatou Krubally and Milca Osorio.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Sanjay Vaid	TELEPHONE: 916-215-7924
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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