197608482-9-27-2022-28-AS-RORN-CJXMWG-20221006095817

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 09/27/2022
Date Signed: 09/27/2022 12:28:47 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/12/2020 and conducted by Evaluator Elizabeth Ceniceros

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20200612090026

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	SHAUN D. RUSHFORTH		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 190	DATE:	09/27/2022
		UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Executive Director, Liyon O'Quinn		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility staff did not assist resident with showering needs.

Facility staff did not ensure that resident is taking medications as prescribed.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

Licensing Program Analyst (LPA)/Retired Annuitant (RA) Elizabeth Ceniceros made an unannounced visit to the facility and was greeted by Executive Director (ED: Liyon O'Quinn). LPA/RA spoke to ED O'Quinn prior to entering the facility to conduct a risk assessment. ED O'Quinn informed LPA/RA that the facility has no COVID cases nor do any of the residents or staff have symptoms.

The purpose of today’s visit is to conduct a subsequent visit to deliver the findings pertaining to the above-mentioned allegations. An initial 10-Day virtual visit was conducted by LPA Angelica Rea on 06/18/20 (via telephone) with (former) Administrator (A1: Shaun Rushforth) due to the situation surrounding the Coronavirus Disease 2019 (COVID-19) and to implement mitigation measures. LPA/RA Ceniceros interviewed (between 8:30 a.m. - 9:00 a.m.) two (2) staff members. Resident #1 no longer resided at the facility, effective 09/2020. LPA/RA reviewed (between 9:30 a.m. – 10:00 a.m.) pertinent documentation: Admission Agreement (dated 09/06/19), Emergency I.D. & Information (dated 08/30/19), Physician’s Report (dated 09/04/19)

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 3

Control Number 28-AS-20200612090026

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2022

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

Pre-placement Appraisal (09/06/19), Care Plan (dated 01/23/20), Health and Wellness Review (dated 01/16/20), Medication Record (June 2020), and Special Incident Report (06/03/20) for Resident #1 (R1). LPA/RA Ceniceros attempted to conduct telephone interviews (via landline) with Complainant, but to no avail; Witness #1's cell was a wrong number, and Resident #1's number was no longer in service.

Regarding Allegation #1: this investigation revealed interviews conducted corroborated that Resident #1 (R1) moved into the facility on 09/06/19 as an "independent" resident and responsible for own self. A review of the Pre-Placement Appraisal (dated 09/06/19) documented no services were needed with R1's bathing or personal hygiene; continence or bladder control. A review of the resident's Physician's Report (dated 09/04/19) documented resident's capacity for self care: able to bathe self: yes; able to groom self: yes; able to care for own toileting needs: yes; bladder impairment: yes. A review of the resident's Health and Wellness Review (dated 01/16/20) documented that Resident #1 is able to transfer/ambulate independently; resident does not require complete bathing assistance, requires no assistance in toileting needs, and does not require wellness (ADLs) check. A Care Plan (01/23/20) was later developed for Resident #1; however, Resident #1 refused basic care needs and healthcare needs from the facility and elected to find services elsewhere for the resident's own care needs. A review of the Special Incident Report (dated 06/03/20) documented that Resident #1 was hospitalized for an unrelated incident and did not return to the facility following hospital discharge, effective 06/03/20.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Facility staff did not assist resident with showering needs is found to be UNSUBSTANTIATED.

Regarding Allegation #2: this investigation revealed interviews conducted corroborated that Resident #1 (R1) moved into the facility on 09/06/19 as an "independent" resident and responsible for own self. A review of the Pre-Placement Appraisal (dated 07/09/19) documented no services were needed with R1's medications. A review of the resident's Physician's Report (dated 09/04/19) documented resident's medication management: able to administer own prescription medications: yes; able to administer own PRN medications: yes; able to store own medications: yes. A review of the resident's Health and Wellness Review (dated 01/16/20) documented that Resident #1 did not require assistance with medications to be administered. Facility maintained a record of the resident's medications (June 2020) for emergency (paramedics or

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 3

Control Number 28-AS-20200612090026

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 09/27/2022

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

hospitalization) purposes. A Care Plan (01/23/20) was later developed for Resident #1; however, Resident #1 refused basic care needs and healthcare needs fromthe facility and elected to find services elsewhere for the resident's own care needs. A review of the Special Incident Report (dated 06/03/20) documented that Resident #1 was hospitalized for an unrelated incident and did not return to the facility following hospital discharge, effective 06/03/20.

Based on the evidence gathered and interviews conducted and records reviewed, although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur; therefore, the allegation of NEGLECT/LACK OF CARE: Facility staff did not ensure that resident is taking medications as prescribed is found to be UNSUBSTANTIATED.

An exit interview has been conducted and a copy of the Complaint Report provided to Executive Director, Liyon O'Quinn.

SUPERVISOR'S NAME: Araceli Ramirez	TELEPHONE: (323) 980-4925
LICENSING EVALUATOR NAME: Elizabeth Ceniceros	TELEPHONE: (916) 264-1579
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 3