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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 07/17/2025
Date Signed: 09/16/2025 03:09:46 PM

Substantiated


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
01/03/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250103151505
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:
07/17/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liyon O'quinnTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Staff did not provide adequate care and supervision to a resident
Staff did not conduct a reassessment of a resident while in care
INVESTIGATION FINDINGS:
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The purpose of this amended report dated 08/16/2025 is to remove specific medical and confidential information in regards to Resident R1 and in addition re- issue regulations that were cited incorrectly on 07/17/2025. The following was done on previous visit 07/17/2025:
Licensing Program Analyst (LPA) Glenn Trueman conducted an unannounced subsequent complaint visit to gather information pertaining to the above-mentioned allegations. LPA met with Executive Director Liyon O'Quinn and explained the reason for the visit.
The initial visit was conducted on 1/13/25 and the following was done:
LPA collected copies of Staff and Resident Rosters. LPA conducted interviews with Executive Director Liyon O'Quinn, Client C1 and Staff S1 and Staff S2.
Interviews were conducted with ALW Representative and Ombudsman Representative telephonically on 3/06/25. Interview with DCHS Representative telephonically on 7/16/25.
At today's visit interviews were conducted with Residents R2- R10.
In regards to the allegation Staff did not provide adequate care and supervision to a resident, based on
Substantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
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-20250103151505
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: 07/17/2025
NARRATIVE
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interviews conducted and information gathered it was revealed by ALW Representative that Resident R1's blood pressure is currently not checked. Stated due to age staff should check for safety on Resident R1 during rounds at nite, but they have not been.
Resident R1 stated she does want to be checked by staff at night, but they have not been.
Stated she is independent at alot of things but still needs help with blood pressure. Also said she has fallen in past and has had dizziness.
Staff stated that R1 is independent with no services and does not need staff to assist her.
Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC9099D.

In regards to the allegation Staff did not conduct a reassessment of a resident while in care, based on interviews conducted and information gathered ALW Representative stated that Resident R1 has a care plan and was assessed by their nurse. Said facility was suppose to reassess and they didn't.
Ombudsman stated that Resident R1 had a care plan and was assessed and met requirements for ALW program.
It was revealed by ALW Representative that Resident R1's blood pressure is currently not checked. Stated due to age staff should check for safety on Resident R1 during rounds at nite, but they have not been.

Staff stated that there was no change in condition so there was no need for reassessment.
Based on interviews conducted and document review, the preponderance of evidence standard has been met, therefore the above allegation is found to be SUBSTANTIATED. Deficiency is being cited according to California Code of Regulations, Title 22. See LIC9099D.

NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5
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
01/03/2025 and conducted by Evaluator Glenn Trueman
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20250103151505

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:
07/17/2025
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Liyon O'quinnTIME COMPLETED:
03:45 PM
ALLEGATION(S):
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9
Staff are retaliating against a resident
Staff are unlawfully evicting a resident
INVESTIGATION FINDINGS:
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It has been alleged that the facility was retaliating because of an appeal that was to be filed in support of Resident R1 and also retaliating by having R1 allegedly face eviction.It has been alleged that the facility has not been providing care services for Resident R1 by not conducting room checks.
In regards to the allegation Staff are retaliating against a resident, based on interviews conducted and information gathered Staff stated that there has not been retaliation.
Stated they feel that they should not take ALW away from some who need the services such as medication management and incontinence care assistance
Resident's R 2-10 stated that staff assist them with all things and have never retaliated on them for any reason. Said in resident council meetings residents voice their concerns and there has not been retaliation.
Interview with Department of Health Care Services (DHCS) Representative who stated Resident R1 is on the ALW Program and if conditions change (R1's husband passing away) and the resident has a contractual obligation signed at admission and the resident can not pay the rate to stay in the private room the facility can offer another room which allows the beneficiary to live in an RCFE approved room.
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.

Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 28-AS-20250103151505
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: 07/17/2025
NARRATIVE
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In regards to the allegation Staff are unlawfully evicting a resident, based on interviews conducted and information gathered ALW Representative stated that there is an Official Form from the state that Resident R1 is enrolled in ALW dated 01/16/24.
Interview with Department of Health Care Services (DHCS) Representative who stated Resident R1 is on the ALW Program and if conditions change (R1's husband passing away) and the resident has a contractual obligation signed at admission and the resident can not pay the rate to stay in the private room the facility can offer another room which allows the beneficiary to live in an RCFE approved room.
Staff interviewed stated that Resident R1 is not being evicted at all. Said it is a transfer still in a private room and it has a shared bathroom.
On 05/17/19 Resident R1 moved into Kingsley Manor and the Addendum To Resident Agreement Document was signed. On that document it states that if they become eligible for financial assistance they will be required to move to the first available private studio apartment with a shared bathroom as a condition of receiving assistance and continued residency at Kingsley Manor.
On 1/10/24 the Amenity Form was submitted with no box checked to waive room. However, this does not supersede the Addendum fro 5/17/2019 signed at time of admission.
Resident R1 stated she has stress and anxiety from possible move and said she spoke with ALW and Ombudsman who stated that she is enrolled in ALW.

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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 28-AS-20250103151505
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/17/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/24/2025
Section Cited
CCR
87463(a)(b)(1)(D)
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Reappraisal
The pre-admission appraisal, as specified in Section 87457, Pre-Admission Appraisal, shall be updated in writing as frequently as necessary or once every 12 months, whichever occurs first, to note significant changes in condition, as defined in Section 87101
The reappraisal shall document significant changes in the resident's physical, mental, cognitive, behavioral, or functional condition and significant including those required to be documented as specified in Section 87466, Observation of the Resident.

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Facility to submit a reassessment of Resident R1 and submit to Licensing by POC due date.

Deficiency cleared. Assessment completed.
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Definitions, include, but are not limited, to:
(D) A mental or social trauma, such as the loss of a loved one.”
This requirement is not met as evidenced by: Appraisal wasn't updated and Resident R1 not being provided safety checks, proper assessment, which caused a potential risk to residents in care.
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Type B
07/24/2025
Section Cited
CCR
87464(f)(1)
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Basic Services
Basic services shall at a minimum include:
(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c).
This requirement is not met as evidenced by:
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Facility to conduct room checks and check blood pressure for Resident R1 as noted on reassessment.

Deficiency cleared. Assessment completed and room checks conducted.
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Facility did not monitor Resident R1's blood pressure and didn't conduct room checks
which caused a potential risk 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.
NAME OF LICENSING PROGRAM MANAGER: Wei Siew Ho
NAME OF LICENSING PROGRAM ANALYST: Glenn Trueman
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/17/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5