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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 07/06/2026
Date Signed: 07/06/2026 05:50:11 PM

Document Has Been Signed on 07/06/2026 05:50 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
MONTEREY PARK ASC, 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: 155DATE:
07/06/2026
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:36 AM
MET WITH:Milka Osorio, Director of Health ServicesTIME VISIT/
INSPECTION COMPLETED:
05:57 PM
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Licensing Program Analyst (LPA) Alberto Lopez conducted an unannounced required 1-yr inspection. LPA met with Chia Demurjan, Interim Executive Director and Milka Osorio, Director of Health Services, and explained the purpose of the visit. The facility is licensed to serve (285) ambulatory residents, (14) non-ambulatory residents, and hospice waiver for (14). Rooms 100, 101-108, 110, 11, 113, 115, 117 are provided for non-ambulatory. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility has Infection prevention and control plan, process, procedures and training plan. Staff are trained in the emergency infection control plan and following hand hygiene techniques. Infection control practices and Personal Protective Equipment (PPEs) were observed. There is a sign-in station located in the main entrance lobby. Emergency and disaster plan was completed and up to date.
Operational Requirements: Infection prevention and control plans have been added to the Plan of Operation. Liability insurance in the amount of ($1,000,000) per occurrence and ($3,000,000) in total annual aggregate is in place and expires on 01/01/2027. Fire and disaster drills are conducted quarterly, and the last drill was last conducted on 06/25/2026. Care and supervision to meet the residents needs was observed. Special equipment and supplies to meet the residents with special needs were observed.
Physical Plant/Environment Safety: The facility contains multiple buildings such as the Administration Building (Main building), Kingsley Manor Care Center, Margaret Hall, Dining Hall, Leitzell Hall, Holly Cottage (Activities area) and the White house. The facility has (5) separate buildings that house residents, a dining room, a kitchen and several public restrooms located throughout the facility. LPA toured random resident rooms in different buildings and observed each bedroom to contain the necessary furnishings and linens. Bathrooms were observed to be clean and equipped with operational grab bars.
NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2026
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/06/2026
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***CONTINUED FROM LIC 809****

The signal system is in various locations and is interconnected with the Fire Department. LPA checked the hot water temperature in random resident rooms and measured within 97.5 – 121.0 Degrees F which is out of range of 105.0 -120.0 degrees F required by Title 22 regulations, Additionally, the facility maintains a log of the water temperature. The common areas, covered patio, movie theater, family room and the main activity room are all located on the top/sixth floor of Leitzell Hall, while the main laundry for residents is in the basement of the building. certain buildings have elevators. The facility has cameras in common areas. The facility is gated with a parking lot that is connected to the main building, and the grounds are well landscaped. The facility has an emergency sprinkler system throughout. All the fire extinguishers were observed to be fully charged, last serviced on 04/06/2026 and in compliance. Cleaning supplies and disinfectants were kept locked and inaccessible to residents. During lunch preparation for residents, kitchen staff were observed wearing hairnets and disposable gloves. Exit doors are free of any obstruction and there are no pools or large bodies of water. There are no security bars or weapons on the premises.


provide care and supervision to the residents. Staff employed are over the age of 18 and have criminal background clearance, fingerprint cleared, have training and are associated with the facility. Night shift staff are trained and able to assist in care and supervision of the residents in case of an emergency.

Personnel Records-Training: Ten (10) staff files were reviewed and confirmed fingerprint clearances, health screenings, vaccinations and 1st Aid/CPR training are current, Administrator certificate is valid and will expire on 05/02/2028.

Residents Rights-Information: The facility has the following posters posted: Residents Rights, Complaint Poster, and Ombudsman. Notice of visiting policy is posted. The facility provides internet services to all residents and has access to the facility phone.

Planned Activities: Activities calendar is up to date and posted. The facility has a Resident Council/Club and meet on a monthly basis. Facility provides equipment and sufficient space to accommodate both outdoor and indoor activities.

CONTINUED

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/06/2026
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(continued from 809C)

Food Service: Director of dining services and LPA toured the kitchen, dining area and food storage in the basement. Sufficient food supply is stored in the kitchen, pantry areas and basement consisting of 2-day perishables, 7-day non-perishables, and emergency food supplies. Sanitation practices and kitchen cleanliness were observed. Kitchen staff workers were observed to be wearing hairnets and using disposable gloves while working and preparing food.

Incidental Medical & Dental: Medications were reviewed containing 30-day supply of medications. Medications are centrally stored, properly labeled and are in their original containers. First aid kit is maintained. Some residents get regular visits from their respective physicians. One resident’s PRN medication did not have labels on.

Resident Records-Incident Reports: A total of (10) resident files were reviewed. They contained Admission Agreements, current Physician's Reports, Pre Placement Appraisal, TB clearance, Functional Capability Assessment, Identification & Emergency Information, Physician's Orders, Medical Consent, and Medication Records.

Disaster Preparedness: Emergency and Disaster Plan LIC 610E is in place, and there is an evacuation chair at the stairwell. LIC610 needs updating on assignments during emergencies.

Residents with Special Health Needs: Director of Health Services stated that the facility retains residents with dementia if they are determined to be appropriate for the facility.

One deficiency cited. Technical violations issued. Exit interview was held and a copy of the report was provided to Chia Demurjan, Interim Executive Director and Milka Osorio, Director of Health Services

NAME OF LICENSING PROGRAM MANAGER: Lisa Hicks
NAME OF LICENSING PROGRAM ANALYST: Alberto Lopez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/06/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2026
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/06/2026 05:50 PM - It Cannot Be Edited


Created By: Alberto Lopez On 07/06/2026 at 05:36 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: 07/06/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, water temperature measured 97.5 - 121.0 which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/10/2026
Plan of Correction
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Administrator adjusted water and will keep a log for 3 days and send to LPA as proof of correction.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Lisa Hicks
NAME OF LICENSING PROGRAM MANAGER:
Alberto Lopez
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/06/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/06/2026


LIC809 (FAS) - (06/04)
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