<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608482
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:00:52 PM


Document Has Been Signed on 09/26/2022 12:00 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: 190DATE:
09/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Executive Director Qunn LiyonTIME COMPLETED:
12:15 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 9/26/2022 at 9:40 a.m., Licensing Programing Analyst (LPA) Jewel Baptiste conducted an unannounced case management inspection at the facility and met with Executive Director Qunn Liyon and Director of Health Services Emyrose Lacuesta to discuss the purpose of the visit, which is to gather information regarding the SOC 341 for Resident #1 (R1).

Per SOC 341 faxed on 8/22/22, R1 reported to facility staff that someone came into the room and touched R1’s private part, but R1 cannot identify who the person was. R1 also do not know the date and the time of the incident.

Report continued on 809c

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:
DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


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
VISIT DATE: 09/26/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
During the visit LPA toured the facility with Director of Health services (Staff #2), interviewed R1, Executive Director, staff #1 and Staff #2. LPA also attempted to interview Charge nurse (staff #3) via phone and left a message. The interviews revealed S1 went into R1’s room to take R1 to lunch. R1 was upset and wanted to make a report. R1 stated to S1 in the morning there was an argument in the room and that person was going to come back and punch R1 in the face. S1 confirmed being with R1 in the morning, but R1 never reported the altercation until lunch time. S1 immediately reported incident to S3. S1 also confirmed that R1 never reported being touched in R1’s private part. According to S2, S3 asked R1 about the incident, and R1 acknowledge having no memory of the altercation. S2 also asked R1 about the incident and R1 also acknowledged having no memory of the altercation. S2 believed there was a misunderstanding with the information passed and reported because they were unsure of the incident. Executive Director confirmed resident is doing great and no other allegations was reported after this incident. LPA interviewed R1 and confirmed that R1 do not remember another person touching R1’s private part. R1 stated to LPA that everything is ok and there are no problems.

During today’s visit, there were no deficiencies cited, per Title 22 regulations. Exit interview conducted and a copy of the report was given to Director Of Health Services Emyrose Lacuesta during the exit interview

SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 213-1556
LICENSING EVALUATOR NAME: Jewel BaptisteTELEPHONE: (323) 400-9594
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2