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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 02/25/2025
Date Signed: 02/25/2025 03:20:03 PM

Document Has Been Signed on 02/25/2025 03:20 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
GREATER LA AC/SC, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KINGSLEY MANORFACILITY NUMBER:
197608482
ADMINISTRATOR/
DIRECTOR:		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
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:20 PM
MET WITH:Administrator Liyon O'QuinnTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted a Case Management VISIT DEFICIENCIES on 02/25/2025, stemming from initial complaint investigation conducted on 02/25/2025. LPA was greeted by Administrator Liyon O’Quinn and explained the purpose of the visit.
Case management deficiencies findings:

On 02/25/2025, LPA Ramirez was conducting resident and staff interviews when it was revealed facility staff do not allow residents to bring outside food into the facility dinning room. Four (4) out of the four (4) staff interviewed corroborated they have been directed to tell residents that no outside food was allowed in the dinning room unless staff approves of the outside food first. Based on interviews conducted, LPA Ramirez will issue a Type B violation for violation of personal rights section 87468.2(a)(3). LPA Ramirez will assess a $250 civil penalty for repeat violations within a 12-month period. The facility was previously cited for violation of section 87468.2(a)(3) on 10/01/2024.



One (1) violation was cited during this visit and one (1) repeat civil penalty was assessed. Exit interview was conducted and a copy of this report was provided via email.
SUPERVISORS NAME: Tony Vasallo
LICENSING EVALUATOR NAME: Kimberly Ramirez
LICENSING EVALUATOR 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.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/25/2025 03:20 PM - It Cannot Be Edited


Created By: Kimberly Ramirez On 02/25/2025 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: KINGSLEY MANOR
FACILITY NUMBER: 197608482

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/25/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
03/04/2025
Section Cited
CCR
87468.2(a)(3)

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87468.2 Additional Personal Rights of Residents in Privately Operated Facilities
(a) In addition to the rights listed in Section 87468.1, Personal Rights of Residents in All Facilities, residents in privately operated residential care facilities for the elderly shall have all of
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This requirement was not met as evidenced by: staff is not allowing residents to bring outside food to eat, into the dinning room.
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the following personal rights:(3) To be encouraged and assisted in exercising their rights as citizens and as residents of the facility. Residents shall be free from interference, coercion, discrimination, and retaliation in exercising their rights.
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Licensee will retrain all staff on this regulation and send proof of retraining by 3/04/2025 via email to LPA Ramirez.

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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:Tony Vasallo
LICENSING EVALUATOR NAME:Kimberly Ramirez
LICENSING EVALUATOR SIGNATURE:
DATE: 02/25/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/25/2025


LIC809 (FAS) - (06/04)
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