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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 07/01/2022
Date Signed: 07/01/2022 01:10:57 PM


Document Has Been Signed on 07/01/2022 01:10 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: 193DATE:
07/01/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Marilou Mendoza, Senior Executive AssistantTIME COMPLETED:
01:20 PM
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Licensing Program Analyst (LPA) Galarza conducted an unannounced Case Management- Incident visit to obtain information on the death of a resident (R1) that occurred on June 26, 2022. The purpose of the visit was explained to Senior Executive Assistant Marilou Mendoza. Executive Director Liyon O'Quinn was explained the purpose of the visit telephonically.

The incident and death report states that on Sunday, June 26, 2022 at 11:40 AM, resident (R1) was found on the ground outside building Leitzel Hall (LH). The resident sustained major injuries. 911 emergency and LAPD responded to the incident. Resident (R1) was pronounced dead at the scene. Preliminary findings indicate the resident fell from it's 5th floor room balcony.

The facility sent facsimile notification to Community Care Licensing Division (CCLD) on June 26, 2022.

LPA toured the exterior facility grounds and resident (R1's) 5th floor room. The balcony railing was observed to be approximately 36 inches (3 ft) high.

The following documents were obtained:


  • Resident (R1's) file documents. Please submit the most recent Physician's Report.
  • Personnel Report/Staff schedule.
  • Resident Roster
  • LAPD incident report #

Facility staff was instructed to obtain resident (R1's) Death Certificate and LA County Coroner's report t and submit to CCLD.

Exit interview was held with Senior Assistant Marilou Mendoza. A copy of the report was issued.

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Noemi GalarzaTELEPHONE: (323) 981-3974
LICENSING EVALUATOR SIGNATURE:
DATE: 07/01/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/01/2022
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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