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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 08/20/2024
Date Signed: 08/20/2024 04:17:01 PM


Document Has Been Signed on 08/20/2024 04:17 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 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: 185DATE:
08/20/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:13 PM
MET WITH:Administrator Liyon O' QuinnTIME COMPLETED:
04:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tyler Reyes conducted an unannounced case-management incident visit in regards to a Special Incident Report (LIC624) that was submitted to Regional Office (RO) on 08/01/24 by facility. LPA Reyes met with Administrator Liyon O’ Quinn and explained the reason for the visit.

Per Special Incident Report on 7/27/24, Resident #1 (R1) reported to staff #1 (S1) that during dinner time R2 was crying, shaking, and stated was afraid of S2. S2 stated while R2 was in the elevator being transported to the dinning area R2 was agitated and tried standing up from wheelchair. S2 stated while in the elevator R2 stood up from the wheelchair, S2 pulled R2 back in the chair, then R2 was yelling and crying in dinning room.

During the Case-Management review of records and interviews were conducted on 08/20/24. LPA Reyes obtained and reviewed documents related to S2’s training, nursing safety standards, and job responsibilities. LPA Reyes conducted interviews with S2-S4 and R1-R4.

Administrator Liyon stated S2 is not employed with facility. Administrator Liyon provide S2’s last day of employment and letter resigning from the facility.LPA Reyes toured the facility and no health and safety concerns were observed during the visit.

Based on interviews, a ciation is being issued. See LIC 809D. An exit interview was conducted. A copy of LIC 809, LIC 809D, & Appeal Rights were provided to Administrator Liyon.

SUPERVISOR'S NAME: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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 08/20/2024 04:17 PM - 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
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754


FACILITY NAME: KINGSLEY MANOR
FACILITY NUMBER: 197608482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/20/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/21/2024
Section Cited
CCR
87468.1(a)(3)

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87468.1 Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (3)To be free from punishment, humiliation, intimidation, abuse, or other actions of a punitive nature..
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Licensee shall provide In-Service Training for all staff focusing on Residents Personal Rights as defined by Title 22 regulations. Licensee shall provide CCL with a copy of the attendance sheet documenting the topics, duration of training, and person that conducted the training by POC Due Date.


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Based on record review and interviews that S2 grabbed R2’s arm while in the elevator which poses an immediate personal rights risks 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: Fernando FierrosTELEPHONE: (323) 981- 3981
LICENSING EVALUATOR NAME: Tyler ReyesTELEPHONE: (323) 981-3306
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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