197608482-12-22-2025-28-AS-FFIS-DQ433U-20260106165406

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197608482
Report Date: 12/22/2025
Date Signed: 12/22/2025 10:50:00 AM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
MONTEREY PARK ASC, 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
08/18/2025 and conducted by Evaluator Luis DeLeon

PUBLIC

COMPLAINT CONTROL NUMBER: 28-AS-20250818141614

FACILITY NAME:	KINGSLEY MANOR		FACILITY NUMBER:	197608482
ADMINISTRATOR:	LIYON O'QUINN		FACILITY TYPE:	740
ADDRESS:	1055 NORTH KINGSLEY DRIVE		TELEPHONE:	(323) 661-1128
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90029
CAPACITY:	299	CENSUS: 164	DATE:	12/22/2025
		UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	HR Director Connie Wilson		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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Staff are threatening resident.
Staff had resident sign a document without resident's authorized representative present

INVESTIGATION FINDINGS:

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** This report supersedes report dated 10/07/2025 to clarify details of findings but there is no change to investigation findings. **
On today’s visit, Licensing Program Analyst (LPA) Luis De Leon conducted a subsequent complaint visit and met with HR Director Connie Wilson. LPA explained the reason for today’s visit was to redeliver the licensing report. LPA was informed that Administrator Liyon O’Quinn was not available for today’s visit. LPA toured residents’ common areas and observed no health and safety risks.

On 10/07/25, Licensing Program Analysts (LPAs) Luis De Leon conducted a subsequent complaint visit to continue investigation for the allegations listed above. LPA met with the Director of Health Services Milca Osorio and explained the reason for the visit. Ms. Osorio stated the Administrator Liyon O’Quinn was not available for the 10/07/25 visit.

Report continues on page LIC-809c

Unsubstantiated

Estimated Days of Completion: 90

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

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

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250818141614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2025

NARRATIVE

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During the initial visit on 08/19/2025, LPA De Leon obtained a copy of the staff and resident rosters and reviewed resident #1 (R1) file and obtained relevant documentation. LPA interviewed Staff #1 (S1) through Staff #3 (S3). LPA obtain copies of communication between billing department and R1 family members, invoices.

Regarding allegation: Staff are threatening resident. It is alleged that the facility is threatening resident 1 (R1) with eviction, if R1 does not pay in full the amount owed for basic services and additional memory care services.

Investigation consisted of interviews with staff, residents and review of R1 facility file, including an eviction notice issued to R1 dated 08/27/2025, and R1’s physician report dated 08/21/2024.

The investigation reveals the following: Seven (7) out of seven (7) staff denied the allegation and stated that staff have never threatened residents. LPA interview with residents revealed that nine (9) out of ten (10) residents denied the allegation above and stated that residents have never been threatened by staff and staff deny issuing an eviction notice to R1 as a threat to R1. LPA interviewed R1 along with R1’s family member who R1 called via telephone, however, R1 did not address LPAs questions regarding the staff threatening R1. LPA record review revealed that R1’s physician report dated 08/21/2024 indicates that R1 is able to leave facility unassisted, able to follow instructions, able to communicate needs, and able to manage R1s own cash resources. Review of R1’s Physician report indicates the R1 is self-responsible and handles R1’s own finances. Additionally, R1’s physician’s report identifies R1 as having Mild Cognitive Impairment (MCI). The facility issued R1 with an eviction notice dated 08/27/2025 due to R1s non-payment for basic services for the period of September 2024 through August 2025, the charges include charges for memory care services.

Report continues on page LIC-809C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 28-AS-20250818141614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2025

NARRATIVE

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On 09/01/2024, an incident occurred when R1 went out into the community and R1 was unable to find a way back to the facility. R1 contacted the staff at facility via telephone to request assistance to find R1s way back to the facility. Staff located R1 around three blocks away from the facility and brought R1 back to the facility. On 09/01/2024, staff reassessed R1 as a result of the 09/01/25 incident, staff determined to place R1 in memory care services to prevent R1 from getting lost in the community and updated R1’s needs and services plan. R1’s additional charges for memory care services included additional charges for wearing a wander guard device that alerts staff in the event that R1 attempts to leave the facility. It was observed that R1 signed the agreement/form titled “Health and Wellness Review” and on 09/03/25, staff notified R1’s family member via email of the form being signed by R1. Since the 09/01/25 incident, the facility reports incidents where staff observed R1 wandering around the facility and knocking on doors to other residents’ room and pulling the facility’s fire alarm. As a result of R1 being lost in the community, and R1 being confused, the facility placed R1 in memory care services for R1’s health and safety. LPA reviewed R1s signed admission agreement dated 08/28/24, which R1 signed on 09/09/24, and LPA observed, under section B of R1s admissions agreement, that the facility is able to terminate the admission agreement for residents’ failure to pay monthly fees. Based upon the investigation, residents and staff interviews, document reviews, and LPA observations, there is no evidence to support that the facility staff are threatening a resident, the investigation revealed that R1 was given an eviction notice which complies with Title 22 regulations.

Regarding allegation: Staff had resident sign a document without resident's authorized representative present. It is alleged that a resident #1 (R1) cannot speak or read English and the facility staff did not ensure that R1 had an authorized representative present when the R1 signed the notice for additional memory care services, which included new monthly fee charges.

Investigation consisted of interviews with staff, residents and review of R1 facility file, including an Health and Wellness Review dated 08/16/2024 (Initial assessment) and 09/01/2024 (Facility Reassessment), and R1’s physician report dated 08/21/2024.

Report continues on page LIC-809C

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

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Control Number 28-AS-20250818141614

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 12/22/2025

NARRATIVE

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The investigation reveals the following: Based on review of R1’s physician’s report dated 08/21/2024, R1’s is able to follow instructions, able to communicate needs, and able to manage own cash resources and R1’s physician’s report dated 08/21/2024 identifies R1 as self-responsible. R1’s Initial Health and Wellness Review dated 08/16/2024, indicates the facility assessed R1’s speech communication status as R1 is able to speak Korean and English is R1’s second language. R1’s Health and Wellness Review dated 09/01/2024, indicates R1’s additional charges for memory care services. It was observed that R1 signed the agreement/form titled “Health and Wellness Review” and on 09/03/25, staff notified R1’s family member via email of the form being signed by R1. Interviews with staff reveal that seven (7) out of seven (7) staff denied the allegation. Staff denied knowing that staff prevent residents, including R1 from consulting a third party before signing facility documents. Interviews with six (6) out of seven (7) staff reveal that interaction between staff and R1 were in English, and R1 English skills are limited. Staff described that R1 can communicate R1’s needs to staff. Interviews with residents reveal that nine (9) out of ten (10) residents feel that they are free to consult with anyone, including a family member or senior assistance center for help if residents prefer to have assistance regarding the review of a facility document, prior to singing the document. Residents stated that they have not felt compelled or forced to sign a document. All nine residents denied the allegation above. LPA interviewed R1 along with R1’s family member who R1 called via telephone, however, R1 did not address LPAs questions regarding the signing of facility documents. Based upon the investigation, client and staff interviews, document review, and LPA observations, R1 is self-responsible and able to sign documents; therefore, R1 does not need to have a representative present to sign documents.

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

Exit interview was held with Director of Health Services Milca Osorio. A copy of the report was provided.

SUPERVISORS NAME: Fernando Fierros
LICENSING EVALUATOR NAME: Luis DeLeon
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2025

LIC9099 (FAS) - (06/04)

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