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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 03/20/2025
Date Signed: 03/20/2025 12:23:53 PM

Substantiated


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
02/10/2025 and conducted by Evaluator Mary G Flores
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250210104613
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: 187DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Salinadou Krubally - Care Service Manager TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff are not meeting resident's food service needs
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Salinadou Krubally Care Service Manager and explained the reason for the visit.

The investigation consisted of the following: On 2/18/25 LPA Flores and LPA Gonzalez conducted an initial complaint investigation visit. During the visit LPAs requested a copy of resident/staff roster, conducted a tour of the dining room, interviewed 5 residents and 5 staff, and requested copies of last two months of menus, alternative menu, and staff training. On 3/20/25 LPA Flores conducted additional interviews with 3 staff and 5 residents and delivered findings.

(CONTINUED ON LIC 9099C)
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
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 5
Control Number 28-AS-20250210104613
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: 03/20/2025
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff are not meeting resident’s food service needs. It is alleged staff are not allowing resident to open own cereal box as requested by the resident due to sanitization concerns. Interviews conducted with residents revealed, 8 out of 10 residents are satisfied with food service, residents do not have service food preferences, and do not have concerns with food not being clean or sanitized. There were 2 out of 10 residents that had concerns with the food and environment not being clean or sanitized and preferring their cereal box being closed rather than open when providing to them. Interviews with staff revealed 8 out of 8 staff stated that the food service is provided under a clean and sanitize environment. Residents have not complaint regarding their cleanness. However, 5 out of 8 staff interviewed stated a resident has requested their cereal box to have a closed lid rather than being provided open to them and have not follow their request as they have been directed to open the lids or boxes. Dining Room Manager stated that it is facility’s practice to peel the bowl’s lid prior to providing it to the residents, residents have not been allowed to do it themselves, and staff must pour the content of the boxes into bowls instead of providing the bowl to residents. Per Dining Room Director, the individual serving bowls of cereal are not always available. Therefore, cereal may be served in a bowl, also the service of the food at the dining room is provided as fine dining and therefore the staff try to assimilate that by providing the food in dishes. During the tour of the dining room LPAs observed individual bowls of cereal store which are provided to the residents for breakfast based on the menu and it was explained to LPA that there are times when they have boxes of cereal which are not for individual serving. Documents reviewed revealed residents are provided the option of dry cereal at least three times a week and have additional or alternative menus to provide a variety of meals per the residents’ choices.

Based on LPAs observations and interviews which were conducted record review(s), the preponderance of evidence standard has been met, therefore the above allegation(s) is found to be SUBSTANTIATED. California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D.

Exit interview was conducted with Milca Osorio Director of Health Services and a copy of this report, LIC 9099D, and appeal rights were provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 28-AS-20250210104613
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 03/20/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/27/2025
Section Cited
CCR
87464(a)
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87464 Basic Services: (a) The services provided by the facility shall be conducted so as to continue and promote ,... independence and self-direction for all persons... shall be encouraged to participate as fully... in daily living activities...
This requirement is not met as evidence by:
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Administrator has implemented dining staff allowing resident to be provide or bring own cereal if necessary into the dining room since LPAs last visit on 2/18/25 and training was provided to staff on resident's rights on 3/3/25. Deficiency cleared as of 3/20/25.
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Based on interviews and observations licensee did not ensure staff were promoting resident's independence and self-direction by allowing choices during meal service which is a potential risk to the health, safety, or personal rights of the persons 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.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
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
02/10/2025 and conducted by Evaluator Mary G Flores
COMPLAINT CONTROL NUMBER: 28-AS-20250210104613

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: 187DATE:
03/20/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Salinadou Krubally - Care Service Manager TIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff is harassing resident
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Mary Flores conducted an unannounced subsequent complaint investigation visit regarding the above allegation. LPA met with Salinadou Krubally Care Service Manager and explained the reason for the visit.

The investigation consisted of the following: On 2/18/25 LPA Flores and LPA Gonzalez conducted an initial complaint investigation visit. During the visit LPAs requested a copy of resident/staff roster, conducted a tour of the dining room, interviewed 5 residents and 5 staff, and requested copies of last two months of menus, alternative menu, and staff training. On 3/20/25 LPA Flores conducted additional interviews with 3 staff and 5 residents and delivered findings.

(CONTINUED ON LIC 9099C)
Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250210104613
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: 03/20/2025
NARRATIVE
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The investigation revealed the following: Regarding allegation: Staff is harassing resident. It is alleged administrator has been bullying resident over the last three years. Interviews conducted with residents revealed, 8 out 10 residents are content with staff, have not observed or been treated disrespectfully by any of the staff members. Two (2) out of 10 residents stated to have either been harassed or have observed staff harassing resident verbally at the facility. Interviews conducted with staff revealed 8 out of 8 staff interviewed stated to address the residents respectfully and have not observed others treat the residents in a disrespectful manner or harassing them in any way. LPA reviewed staff training conducted on 1/9/25 regarding residents’ personal rights.

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 was conducted with Milca Osorio Director of Health Services and a copy of this report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Mary G Flores
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5