197608482-8-6-2024-28-AS-RORN-D92KXE-20240912081722

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:26:00 PM

Unsubstantiated

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
07/29/2024 and conducted by Evaluator Bonnie Tao

COMPLAINT CONTROL NUMBER: 28-AS-20240729195058

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: 187	DATE:	08/06/2024
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Liyon O'Quinn, administrator		TIME COMPLETED:	01:30 PM

ALLEGATION(S):

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Staff are not properly positioning a resident.
Staff do not meet a resident's toileting needs.
Resident developed pressure injuries while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tao conducted an unannounced initial 10-day complaint investigation regarding the above allegations. LPA discussed the purpose of the visit with Liyon O'Quinn, Executive Director.

The investigation consisted of the following:
LPA interviewed staff from staff#1 (S1) to staff #4 (S4); interviewed residents from resident #1 (R1) to resident #8 (R8); obtained resident roster and staff roster; reviewed facility file of resident#1; and conducted a physical plant.

The investigation revealed of the following:
Regarding the allegation of staff are not properly positioning a resident, it was alleged that staff did not position resident#1 (R1) during the day. LPA interviewed residents, all eight (8) residents could not corroborate the allegation. (-continued on LIC 9099 C-)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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-20240729195058

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: 08/06/2024

NARRATIVE

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R1 was interviewed and stated resident could position by himself/herself. LPA interviewed staff and all staff denied the allegation. Staff interviews indicated that residents could position by themselves. Per record review, resident only needed assistance with transferring to/from bed to wheelchair/recliner. Therefore, staff did not fail to position residents while in care.

Regarding the allegation of staff do not meet a resident's toileting needs, it was alleged that staff did not assist resident#1 (R1) for toileting needs during the day. Per resident interviews, all eight (8) residents could not corroborate the allegation. Resident interviews revealed staff assisted residents with toileting needs including checking on residents a few times day and changing residents’ briefs a few times. Per staff interviews, all staff denied the allegation. Staff interviews indicated that staff would check on residents for their toileting needs in the morning, afternoon, and bedtime. Per LPA’s observation, residents had no foul odor or urine smell during interviews. Residents were observed to be clean. Therefore, staff did not fail to meet resident’s toileting needs while in care.

Regarding the allegation of resident developed pressure injuries while in care, it was alleged that resident had pressure injuries. LPA interviewed residents, all eight (8) residents could not corroborate the allegation. None of the residents had or aware of any pressure injuries. LPA interviewed staff and all staff denied the allegation. Staff interviews indicated that no residents had pressure injuries at the facility. Per record review, resident did not have pressure injuries. Therefore, resident did not develop pressure injuries while in care.

Although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation(s) did or did not occur, therefore, the allegation is UNSUBSTANTIATED.

Exit interview held with administrator. A copy of the report was provided.

SUPERVISOR'S NAME: Fernando Fierros	TELEPHONE: (323) 981-3981
LICENSING EVALUATOR NAME: Bonnie Tao	TELEPHONE: (323) 981-3971
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC9099 (FAS) - (06/04)

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