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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 02/03/2023
Date Signed: 02/03/2023 11:08:33 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
GREATER LA AC/SC, 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
08/31/2020 and conducted by Evaluator Kimberly Ramirez
PUBLIC
COMPLAINT CONTROL NUMBER: 28-AS-20200831135015
FACILITY NAME:KINGSLEY MANORFACILITY NUMBER:
197608482
ADMINISTRATOR:SHAUN D. RUSHFORTHFACILITY TYPE:
740
ADDRESS:1055 NORTH KINGSLEY DRIVETELEPHONE:
(323) 661-1128
CITY:LOS ANGELESSTATE: CAZIP CODE:
90029
CAPACITY:299CENSUS: 190DATE:
02/03/2023
UNANNOUNCEDTIME BEGAN:
09:13 AM
MET WITH:Executive Director Liyon O'QuinnTIME COMPLETED:
11:00 AM
ALLEGATION(S):
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Facility is in disrepair, leaking air conditioner
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Kimberly Ramirez conducted an unannounced subsequent complaint investigation regarding the above allegation. LPA was met by Administrator Liyon O’Quinn and explained the purpose of the visit.

The investigation consisted of the following: LPA requested and obtained a copy of Staff roster, Resident roster, Plan of Operation, and current admission packet. LPA Ramirez interviewed Staff 1 – Staff 5 (S1 - S5), and Resident 1 – Resident 4 (R1- R4). LPA Ramirez toured kitchen and dining room during lunch time and 4 resident rooms at 1:55 pm.


Unsubstantiated
Estimated Days of Completion:
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
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 2
Control Number 28-AS-20200831135015
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		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 MANOR
FACILITY NUMBER: 197608482
VISIT DATE: 02/03/2023
NARRATIVE
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The investigation revealed the following: regarding the allegations: “Facility is in disrepair, leaking air conditioner,” it is alleged the facility has not repaired a leaking air conditioner. Five out of five staff denied this allegation. Staff allege when residents report their window air conditioning unit is not working, they will attempt to fix it or replace the unit within a few days. Four out of the four residents interviewed denied having any issues with their air conditioning unit. LPA observed resident window air conditioning unit in resident rooms AD-219, AD-308, and LH-123 to be operational.

Although the allegation may have happened or are valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur, therefore the allegation is UNSUBSTANTIATED.

Exit interview was conducted with Executive Director Liyon O’Quinn. A copy of the report was provided.
NAME OF LICENSING PROGRAM MANAGER: Tony Vasallo
NAME OF LICENSING PROGRAM ANALYST: Kimberly Ramirez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2