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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:19:26 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
02/19/2025 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250219110211
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: 172DATE:
02/25/2025
UNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Administrator Liyon O'QuinnTIME COMPLETED:
03:00 PM
ALLEGATION(S):
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Staff's negligence led to resident's property being damaged.
Staff do not follow infection control guidelines.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced initial complaint investigation visit on 02/25/2025 regarding the above allegations. LPA was greeted by 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, Staff Roster (LIC 500), Staff#1 - 4 interviews (S1 – S4), Interview of residents#1-10 (R1 – R10), copies of Resident#1 (R1): Admission Agreement, recent Physician Report, resident, family, or visitor concern/grievance form, signed statement from the Resident Services Director, copy of infection control plan and physical plant tour.

SEE 9099-C for continued report.
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
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-20250219110211
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: 02/25/2025
NARRATIVE
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The investigation revealed the following. Regarding Allegation(s): Staff's negligence led to resident's property being damaged – It is alleged on or around 11/12/2024, staff knocked over R1’s denture container and caused the container to break and spill out contents inside. Four (4) out of the four (4) staff interviewed denied this allegation. Eight (8) out of the ten (10) residents interviewed denied this allegation. Interview with R1 alleged, R1 left their room and R1’s denture container was sitting on their bathroom sink when R1 left their room. R1 revealed when they came back into their room within the hour, R1 noticed their denture container had a crack and hole on the lower bottom corner and the fluid inside the container was now all over the bathroom floor. R1 revealed they tried to insert their dentures back into their mouth, but the dentures no longer fit due to shrinkage. Staff interviews revealed staff did not knock over or touch R1’s denture container. 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 do not follow infection control guidelines- It is alleged staff do not follow facility infection control guidelines. Four (4) out of the four (4) staff interviewed denied this allegation. Eight (8) out of the ten (10) residents interviewed denied this allegation. During facility tour, LPA Ramirez observed staff wearing gloves while handling food, disinfecting high trafficked areas, and cleaning resident rooms. LPA Ramirez reviewed facility infection control plan. Staff interviews revealed staff is well versed on infection control practices. 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 violations were cited for this investigation. Exit interview was conducted and a copy of this report was provided via email.

NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/25/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2