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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 06/14/2022
Date Signed: 06/14/2022 05:00:11 PM


Document Has Been Signed on 06/14/2022 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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: 198DATE:
06/14/2022
TYPE OF VISIT:Case Management - COVID-19UNANNOUNCEDTIME BEGAN:
04:20 PM
MET WITH:Liyon O'Quin, Executive DirectorTIME COMPLETED:
05:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Galarza made an unannounced visit for the purpose of an unrelated complaint investigation control # 28-AS-20220613092610. LPA met with Executive Director Liyon O'Quin and discussed the purpose of the visit.

LPA was screened for COVID-19 upon arrival at the facility. LPA learned there is one (1) active COVID-19 case that was not reported to Community Care Licensing. Resident (R1) tested positive on June 9, 2022, and is presently being isolated in it's room. The facility is presently conducting surveillance testing twice a week.

LPA verified at the Regional Office and no COVID-19 cases have been reported since March 2022.

Per Title 22, Division, 6, Chapter 8; 87211 Reporting Requirements deficiency has been cited. See LIC 809D.

Exit interview was held with Executive Director. A copy of this report and appeal rights were provided.


SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 06/14/2022 05:00 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 06/14/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/21/2022
Section Cited

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Reporting Requirements: Each licensee shall furnish to the licensing agency such reports as the Department may require, including, but not limited to, the following: (2) Occurrences, such as epidemic outbreaks, poisonings, catastrophes or major accidents .... shall be reported within 24 hours either by telephone or facsimile to the licensing agency and to the local health officer when appropriate.
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This requirement was not met evidenced by: On June 9, 2022 R1 tested positive for COVID-19 virus. The facility did not call CCL to report the case, and has not submitted an incident report to CCL; which poses a potential health and safety risk to 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.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 06/14/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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