197608482-10-1-2024-28-AS-TVAO-DA3M2C-20241015091316

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 10/01/2024
Date Signed: 10/01/2024 04:25:32 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
09/03/2024 and conducted by Evaluator Kimberly Ramirez

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20240903221616

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: 190	DATE:	10/01/2024
		UNANNOUNCED	TIME BEGAN:	08:37 AM
MET WITH:	Administrator Liyon O'Quinn		TIME COMPLETED:	02:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Staff is illegally evicting resident.
Staff confiscated resident's belonging.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation visit on 10/01/2024 regarding the above allegations. Licensing Program Analyst (LPA) Nune Margaryan conducted inital complaint investigation visit on 09/12/24 and needs further investigation was documented, LPA Ramirez was greeted Administrator Liyon O'Quinn and explained the purpose of the visit.

The investigation consisted of the following: LPA Ramirez requested and obtained copies of Resident/Client Roster (LIC 9020), Staff#1 - 3 interviews (S1 – S3), Interviews of Residents#1-2 (R1-R2), copies of Resident#R1 (R1) Physician’s Report, R1’s Admission Agreement dated 09/23/2021, 30-Day Notice to Terminate dated 08/23/2024, Violation of Rental Agreement Notices from 09/06/2024 through 12/29/2023 for R1, Written witness statements dated 08/18/2024, and 08/17/2024, and campus site map and physical plant tour.

See 9099-C for continued narrative.

Unsubstantiated

Estimated Days of Completion:

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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 2

Control Number 28-AS-20240903221616

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 10/01/2024

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
26
27
28
29
30
31
32

The investigation revealed the following. Regarding Allegations: Staff is illegally evicting resident- It is alleged the facility is illegally evicting R1. On 09/30/2021, R1 was admitted into the facility. R1 is not conserved and is self responsible. On 08/23/2024, R1 was served with a 30-Day Notice to Terminate. LPA Ramirez reviewed the 30-Day Notice to Terminate for R1 and observed this notice to contain the effective date of eviction, reasons relied upon for the eviction with specific facts to permit determination of the date, witness, and circumstances concerning those reasons and resources available to assist in identifying alternative housing and care options which include, but are not limited to, the following: Referral services that will aid in finding alternative housing, and case management organizations which help manage individual care and service needs. Three (3) out of the three (3) staff interviewed deny this allegation. One (1) out of the two (2) residents interviewed deny this 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.

Staff confiscated resident's belonging- It is alleged staff confiscated R1’s walker while R1 dined in the dining room. Three (3) out of the three (3) staff interviewed deny the allegation. Interview with staff revealed dining room staff will temporarily relocate residents’ walkers to corner in the dining room or outside the dining room doors, as to not impede dining walkways. Staff revealed once residents are finished with their meals and request their walker back, staff will bring the walker to the resident. Interview with R1 revealed staff confiscate R1’s walker but returned it after R1 is finished dining. Two (2) out of two (2) residents interviewed deny this 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.

No deficiency was cited for this investigation. Exit interview was conducted. A copy of this report was provided by via email due to printer problems.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2