197608482-12-17-2021-28-AS-MVAO-CALUQD-20220112144659

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 12/17/2021
Date Signed: 12/17/2021 11:19:03 AM

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
04/29/2021 and conducted by Evaluator Alma Gonzalez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20210429115247

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	SHAUN D. RUSHFORTH		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 181	DATE:	12/17/2021
		UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Liyon O'Quinn		TIME COMPLETED:	11:30 AM

ALLEGATION(S):

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Resident was raped by a staff member

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Alma Gonzalez conducted a subsequent complaint visit to deliver investigation findings for the above stated allegation. LPA met with Executive Director Liyon O'Quinn and explained the reason for the visit.

Investigation consisted of the following: During the initial visit conducted on 4/30/21, LPAs David Sicairos and Luis Mora requested copies of staff and resident rosters and conducted a tour of facility and common areas. LPAs observed a sufficient supply of perishable and non-perishable foods. LPAs observed the residents to identify any signs of neglect, abuse, or other immediate health and safety threats. LPAs did not observe any immediate health and/or safety concerns during the visit. On 4/29/21, LPA Gonzalez received a call from Executive Director Ted Maneerod who informed LPA of the alleged incident and received a copy of Unusual Incident/ Reports dated 4/27/21 and 4/28/21, SOC341 and copy of LAPD card with Incident Number.

(See LIC 9099C for continuation of report)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

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-20210429115247

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: 12/17/2021

NARRATIVE

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The investigation for this complaint was conducted by Investigator Laura Garcia.

During the course of this investigation, Investigator Garcia conducted interviews with Resident 1 (R1), R1's FM, Facility Administrator Randy Herzig, Private Caregivers 1-3 (PC1-3), Facility Caregiver Gemma DeLeon, and R2. Investigator Garcia received Hospital Medical Records on 6/29/21. Investigator Garcia also attempted to request LAPD incident report but did not receive a copy from police department.

The investigation revealed the following: Regarding allegation of, Resident was raped by a staff member, on 8/17/21, Investigator Garcia interviewed R1 who was aware of the allegation and provided a statement to Investigator but when asked if R1 could name the person or describe the suspect, R1 stated a certain name but was unable to provide specific details of the incident. Investigator stated that it was apparent that R1 was having cognitive issues and displayed confusion during the interview. R1's FM and Investigator Garcia agreed that due to R1's diagnoses it was best to conclude the interview. R1 denied any type of neglect/ lack of supervision on behalf of staff and expressed that they felt safe at the facility.

On 8/17/21, Investigator interviewed R1's FM who confirmed that their family member (R1) was unable to provide any detail of the alleged suspect. R1's FM stated that they are aware that R1 suffers from delirium and is cognitively impaired due to diagnosis of Major Neurocognitive Disorder. R1's FM stated that they also confirmed with R1's doctor that they have a difficult time processing reality and identifying facts due to mental diagnosis. R1's FM did not express concerns and stated that R1 seems happy at the facility and also feels safe.

On 8/16/21, Investigator Garcia interviewed PC1 who stated that R1 was assigned two female caregivers and due to R1's weight the female caregivers would request help from a male caregiver to assist them with transferring R1 to their bed and stated that there was no physical touching or assisting with changing R1.

On 8/18/21, Investigator Garcia interviewed Facility Caregiver Gemma DeLeon who denied that there are any male staff assisting R1. Staff DeLeon denied that PC3 was ever left alone with R1 without another staff present. Staff DeLeon stated that she and PC2 are assigned to R1 and they have requested PC3's assistance due to R1's bed being high and R1's weight. She stated that PC3 briefly assisted with moving R1 only from

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20210429115247

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: 12/17/2021

NARRATIVE

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the wheelchair to the bed. She also stated that PC3 did not touch R1 and that PC3 is very professional and cares for the resident. She stated that both she and PC2 are always aware of R1's well being and are always in line of sight of R1.

On 8/18/21, Investigator Garcia interviewed PC2 who denied the allegation and indicated that PC3 would occasionally assist with transferring R1. PC2 stated that they never witnessed anything inappropriate from any other staff members and explained that PC3 would be in and out of the room and only helped due to R1's weight and the height of R1's bed. PC2 stated that PC3 is a very nice and professional individual.

On 8/23/21, Investigator Garcia interviewed PC3 who denied sexually assaulting R1. PC3 stated that the caregivers assigned to R1 would often ask for assistance with lifting R1 off of their wheelchair and onto their bed. PC3 stated that the most it took to assist was 5 minutes or less and PC3 would then return to their assigned resident. PC3 stated that they would never do such a thing.

On 8/23/21, Investigator Garcia interviewed R2 who stated that they have lived at the facility for 17 years, feels safe and has never witnessed or heard anything unusual by any of the staff members or other residents. R2 denied any type of neglect/ lack of supervision and described staff to be extremely helpful and attentive to their needs. R2 stated that they are satisfied with the level of care provided by all staff members.

Investigator Garcia's review of hospital medical records revealed that based on R1's psychiatric issues and medical assessment regarding "adult sexual abuse", it was discovered that there were no apparent trauma or complaints made by R1 and R1 returned to the facility with no additional concerns.

Based on interviews conducted with R1-2, R1's FM, PC1-3, facility staff, and Investigator Garcia's review of hospital records there was not enough supportive evidence to concur with the reported allegation.

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 held. A copy of the report was provided to Executive Director Liyon O'Quinn.

SUPERVISOR'S NAME: Rebecca Orendain	TELEPHONE: (323) 981-3961
LICENSING EVALUATOR NAME: Alma Gonzalez	TELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:	DATE: 12/17/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/17/2021

LIC9099 (FAS) - (06/04)

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