197608482-10-7-2025-28-AS-FFIS-DQ433V-20260106165407

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 10/07/2025
Date Signed: 10/07/2025 05:23:01 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/18/2025 and conducted by Evaluator Luis DeLeon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250818141614

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: 177	DATE:	10/07/2025
		UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Director of Health Services		TIME COMPLETED:	05:15 PM

ALLEGATION(S):

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Staff are threatening resident
Staff had resident sign a document without resident's authorized representative present

INVESTIGATION FINDINGS:

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Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint visit to continue investigation for the allegations listed above. LPA met with the Director of Health Services Milca Osorio and explained the reason for today’s visit. Ms. Osorio stated the Administrator Liyon O’Quinn was not available for today’s visit.

During the initial visit on 08/19/2025, LPA De Leon obtained a copy of the staff and resident rosters and reviewed resident #1 (R1) file and obtained relevant documentation. LPA interviewed Staff #1 (S1) through Staff #3 (S3). LPA obtain copies of communication between billing department and R1 family members, invoices.

On today’s visit, LPA toured residents’ common areas and observed no health and safety risks. LPA conducted interviews with residents and staff.
Report continues on page LIC-809c.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

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-20250818141614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 10/07/2025

NARRATIVE

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Regarding allegation: Staff are threatening resident.
It is alleged that the facility is threatening resident 1 (R1) with eviction if R1 does not pay the full amount owed for unpaid monthly fees and additional charges to prevent R1 from eloping. It is alleged that the responsible family member was not present to sign off for additional fee and family member did not agree with R1 needing additional services. The investigation reveals the following: After an incident where R1 eloped from the facility on 09/01/2024, the facility reassessed R1. On 09/01/2024, the facility identified R1’s risk of eloping which resulted in staff providing additional service to prevent R1 from eloping from the facility. Due to change of condition, R1 agreed to wear the monitor bracelet and signed the rate increases form with the effective date of 09/01/2024. The facility added services to R1, which consisted of frequent wellness check and monitoring bracelet to alert staff when R1 is attempting to exit the facility. The facility informed R1’s family member on 09/03/2024 via email of fee increase. Based on initial physician’s report dated 08/21/2024, R1’s assessment was reported to be able to follow instructions, able to communicate needs, and able to manage own cash resources. The physician’s report identifies R1 as self-responsible. In addition, LPA’s facility’s invoice review for the period of 08/29/2024 through 08/01/2025 reveals that R1’s last payment for basic service was made on 04/07/2025, which did not pay the outstanding balance in full. Interview with residents reveal that ten (10) out of ten (10) residents denied the allegation. Seven (7) out of seven (7) staff denied the allegation. Based upon the investigation, client and staff interviews, document review, and LPA observations, the facility’s notice to collect on past due account and warning R1 or family member that evection process may be started is not a threat.

Report continues on page LIC-809C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250818141614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR	FACILITY NUMBER: 197608482
	VISIT DATE: 10/07/2025

NARRATIVE

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Regarding allegation: Staff had resident sign a document without resident's authorized representative present
It is alleged that the facility did not ensure that an authorized representative was present when R1 signed off the notice for additional services that were added to the monthly basic service fees. It is alleged that R1 cannot speak or read English. The investigation reveals the following: Based on initial physician’s report dated 08/21/2024, R1’s assessment was reported to be able to follow instructions, able to communicate needs, and able to manage own cash resources. The physician’s report identifies R1 as self-responsible. Based on initial Health and Wellness Review dated 08/16/2024, the facility assessed R1’s speech communication status as able to “speak Korean English is second language.” Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied knowing any staff preventing residents from consulting a third party before signing a facility document. Interviews with six (6) out of seven (7) staff reveal that interaction between staff and R1 were in English, although R1 English skills are limited, R1 was able to communicate his needs. Interviews with residents reveal that ten (10) out of ten (10) residents feel that they are free to consult with any family or senior assistance center for help in the event that residents do not understand a document. All residents denied the allegation above. Residents stated that they have not felt compelled to sign a document without reading it before or getting assistance if they don’t understand the document. LPA’s document review revealed that based on initial physician’s report dated 08/21/2024, R1’s assessment was reported to be able to follow instructions, able to communicate needs, and able to manage own cash resources. The physician’s report identifies R1 as self-responsible. Based upon the investigation, client and staff interviews, document review, and LPA observations, R1 is self-responsible and able to sign documents. The residents are free to consult family before signing any document as stated by residents’ interview.

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 held with Director of Health Services Milca Osorio. A copy of the report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 10/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2025

LIC9099 (FAS) - (06/04)

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