Inspection Reports for Kingsley Manor
1055 N Kingsley Dr, Los Angeles, CA 90029, United States, CA, 90029
Back to Facility ProfileInspection Report Summary
Most inspections found no deficiencies, with the facility generally meeting regulatory standards for infection control, safety, staffing, and resident care. Several complaint investigations were unsubstantiated, including allegations of financial abuse, improper eviction, and staff misconduct. However, some deficiencies were cited over time, primarily related to resident care such as failure to assist with showering, medication management issues, personal rights violations, and environmental concerns like pest infestations and elevator disrepair. The most recent report from September 9, 2025, was clean with no deficiencies noted. Overall, the facility shows some improvement in addressing prior issues, though isolated care and rights-related deficiencies have occurred intermittently.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
3.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
8% better than California average
California average: 4 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
59% occupied
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 177
Capacity: 299
Deficiencies: 0
Sep 9, 2025
Visit Reason
The visit was a 24-hour Case Management incident visit conducted due to an allegation by resident 1 (R1) that staff 1 (S1) inappropriately touched R1 on 2025-09-07.
Findings
Licensing Program Analysts conducted a physical plant tour and did not observe any health and safety risks to residents. Records for resident 1 and staff 1 were reviewed, and R1 was interviewed regarding the allegation.
Complaint Details
Resident 1 alleged that staff 1 inappropriately touched them on 2025-09-07. Licensing Program Analysts interviewed resident 1 and reviewed relevant records. No deficiencies or severity levels were documented in the report.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met with Licensing Program Analysts during the incident visit and participated in the exit interview. |
Inspection Report
Annual Inspection
Census: 177
Capacity: 299
Deficiencies: 0
Aug 12, 2025
Visit Reason
An unannounced required 1-year inspection was conducted to evaluate compliance with licensing requirements and assess the facility's operations, infection control, safety, staffing, and resident care.
Findings
The facility was found to be in compliance with all licensing requirements with no deficiencies cited. Infection control practices, safety measures, staffing, food service, and resident care were all observed to meet regulatory standards. A technical violation was issued.
Report Facts
Staff members on roster: 107
Staff files reviewed: 10
Resident files reviewed: 10
Food supply duration: 2
Food supply duration: 7
Liability insurance coverage: 1000000
Liability insurance coverage: 3000000
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Executive Director | Met with Licensing Program Analyst during inspection and received copy of report |
| Milka Osorio | Director of Health Services | Met with Licensing Program Analyst and provided information on residents with special health needs |
| Bennette Pena | Licensing Program Analyst | Conducted the unannounced required 1-year inspection |
| David Sicairos | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 299
Deficiencies: 0
Jul 29, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility was charging a resident for services not rendered.
Findings
The investigation found that the resident was receiving the services identified by a re-assessment to prevent eloping, and that seven out of eight residents denied the allegation. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that the facility charged a resident for additional services without informing or obtaining consent from the resident's responsible party, and that the additional fee was not listed in the admission agreement. The investigation included interviews, document reviews, and observations, concluding the allegation was unsubstantiated.
Report Facts
Residents denying allegation: 7
Staff denying involvement: 5
Incident date: Aug 29, 2024
Rate increase effective date: Sep 1, 2024
Date family email: Jul 24, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Director | Met with Licensing Program Analyst during investigation and involved in billing and rate increase discussions. |
| Luis DeLeon | Licensing Program Analyst | Conducted the unannounced complaint investigation visit. |
| Fernando Fierros | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation. |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 299
Deficiencies: 2
Jul 17, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by complaints alleging inadequate care and supervision, failure to conduct reassessment, retaliation against a resident, and unlawful eviction.
Findings
Two allegations were substantiated: staff did not provide adequate care and supervision to Resident R1, including failure to check blood pressure and conduct room checks, and staff did not conduct a reassessment of Resident R1 while in care. Two allegations were unsubstantiated: staff retaliating against a resident and unlawfully evicting a resident. Deficiencies were cited under California Code of Regulations, Title 22.
Complaint Details
The complaint investigation was substantiated for allegations that staff did not provide adequate care and supervision and failed to conduct reassessment for Resident R1. The allegations of staff retaliation and unlawful eviction were unsubstantiated.
Severity Breakdown
Type B: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to update pre-admission appraisal and provide safety checks and proper assessment for Resident R1, causing potential risk to residents in care. | Type B |
| Failure to conduct room checks and monitor Resident R1's blood pressure, causing potential risk to residents in care. | Type B |
Report Facts
Capacity: 299
Census: 187
Deficiency count: 2
Plan of Correction Due Date: 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation and cited deficiencies |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation |
| Liyon O'Quinn | Administrator / Executive Director | Facility administrator met during investigation and involved in interviews |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 299
Deficiencies: 1
Mar 20, 2025
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff were not meeting residents' food service needs and that staff were harassing a resident.
Findings
The allegation regarding food service needs was substantiated, finding that staff did not promote resident independence by not allowing residents to open their own cereal boxes, which was corrected by the facility. The allegation of staff harassing a resident was unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not meeting residents' food service needs, specifically regarding residents not being allowed to open their own cereal boxes. The allegation that staff were harassing a resident was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Licensee did not ensure staff were promoting resident's independence and self-direction by allowing choices during meal service, posing a potential risk to health, safety, or personal rights. | Type B |
Report Facts
Capacity: 299
Census: 187
Deficiencies cited: 1
Plan of Correction Due Date: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and authored the report |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
| Salinadou Krubally | Care Service Manager | Met with Licensing Program Analyst during the investigation |
| Milca Osorio | Director of Health Services | Participated in exit interview and received report copy |
| Liyon O'Quinn | Administrator | Named in harassment allegation investigation |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 299
Deficiencies: 0
Feb 25, 2025
Visit Reason
An unannounced complaint investigation visit was conducted on 02/25/2025 regarding allegations of staff negligence leading to resident's property damage and staff not following infection control guidelines.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and most residents denied the claims, and observations showed staff following infection control practices. Therefore, both allegations were unsubstantiated and no violations were cited.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff negligence causing damage to a resident's denture container and failure to follow infection control guidelines. Interviews and observations did not provide a preponderance of evidence to prove the allegations.
Report Facts
Residents interviewed: 10
Staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation visit |
| Liyon O'Quinn | Administrator | Facility administrator met with during the investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 172
Capacity: 299
Deficiencies: 1
Feb 25, 2025
Visit Reason
The visit was a Case Management inspection stemming from an initial complaint investigation conducted on 02/25/2025 regarding facility policies on residents bringing outside food into the dining room.
Findings
One Type B violation was cited for violation of personal rights section 87468.2(a)(3) due to staff prohibiting residents from bringing outside food into the dining room without staff approval. A $250 civil penalty was assessed for repeat violations within a 12-month period.
Complaint Details
The visit was triggered by an initial complaint investigation. The violation was substantiated and a repeat civil penalty was assessed.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Violation of personal rights section 87468.2(a)(3) related to prohibiting residents from bringing outside food into the dining room without staff approval. | Type B |
Report Facts
Civil penalty amount: 250
Number of violations cited: 1
Number of staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the case management visit and cited the violation |
| Liyon O'Quinn | Administrator | Facility administrator met with the Licensing Program Analyst during the visit |
| Tony Vasallo | Supervisor | Named as supervisor in the report |
Inspection Report
Census: 177
Capacity: 299
Deficiencies: 0
Feb 20, 2025
Visit Reason
The visit was a Case Management - Incident unannounced inspection conducted to investigate an unusual incident report involving a former resident who was allegedly force fed by a private caregiver prior to passing away.
Findings
The Licensing Program Analyst conducted a health and safety check and interviews with staff and family members. No signs of neglect, abuse, or immediate health and safety threats were observed during the visit.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met with during the inspection and named in the report. |
| Milca Osorio | Director of Health Services | Met with during the inspection and named in the report. |
| Nune Margaryan | Licensing Program Analyst | Conducted the Case Management - Incident visit. |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 299
Deficiencies: 0
Oct 1, 2024
Visit Reason
An unannounced complaint investigation visit was conducted regarding allegations that staff were illegally evicting a resident and confiscating the resident's belongings.
Findings
The investigation found insufficient evidence to substantiate the allegations. Staff and residents interviewed denied the allegations, and no deficiencies were cited.
Complaint Details
The complaint involved allegations that staff illegally evicted a resident and confiscated the resident's walker. The investigation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 299
Census: 190
Staff interviewed: 3
Residents interviewed: 2
Notice to Terminate date: Aug 23, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Liyon O'Quinn | Administrator | Facility administrator met during investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 299
Deficiencies: 1
Oct 1, 2024
Visit Reason
The visit was a Case Management - Deficiencies inspection conducted on 10/01/2024, stemming from a subsequent complaint investigation conducted on the same date.
Findings
One Type B violation was cited related to a resident's personal rights, specifically regarding the resident's right to smoke away from the facility, which was found to be within their rights as a citizen.
Complaint Details
The visit was triggered by a complaint investigation. The violation was substantiated as a Type B violation for personal rights.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Violation of Admission’s Agreement due to resident smoking away from the facility, related to personal rights under Title 22, 87468.2(a)(3). | Type B |
Report Facts
Distance from smoking location to main door: 45.75
Deficiencies cited: 1
Capacity: 299
Census: 190
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the Case Management Visit-Deficiencies and complaint investigation. |
| Liyon O'Quinn | Administrator | Facility administrator met with the Licensing Program Analyst during the visit. |
| Tony Vasallo | Supervisor | Supervisor named in the report. |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 299
Deficiencies: 1
Aug 20, 2024
Visit Reason
An unannounced case-management incident visit was conducted in response to a Special Incident Report submitted by the facility regarding a resident's report of fear and agitation involving staff.
Findings
The investigation found that staff member S2, who was no longer employed at the facility, grabbed a resident's arm in an elevator, posing an immediate personal rights risk. No other health and safety concerns were observed during the visit.
Complaint Details
The visit was complaint-related based on a Special Incident Report submitted on 08/01/2024. The complaint involved Resident #2 being afraid of staff member S2, who was found to have grabbed the resident's arm. The complaint resulted in a citation being issued.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Residents in all residential care facilities for the elderly shall have the right to be free from punishment, humiliation, intimidation, abuse, or other punitive actions. Based on record review and interviews, S2 grabbed R2’s arm while in the elevator, posing an immediate personal rights risk. | Type A |
Report Facts
Deficiencies cited: 1
Capacity: 299
Census: 185
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O' Quinn | Administrator | Met during inspection and provided information about staff S2's employment status |
| Tyler Reyes | Licensing Program Analyst | Conducted the inspection and interviews |
| Fernando Fierros | Supervisor | Supervisor overseeing the inspection |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 299
Deficiencies: 0
Aug 6, 2024
Visit Reason
An unannounced complaint investigation was conducted in response to allegations received on 2024-07-29 regarding improper resident positioning, unmet toileting needs, and development of pressure injuries at Kingsley Manor.
Findings
The investigation found no corroboration for the allegations after interviews with residents and staff, record reviews, and observations. Staff were found to assist residents appropriately, and no pressure injuries were identified. The allegations were determined to be unsubstantiated due to lack of evidence.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff not properly positioning a resident, not meeting toileting needs, and a resident developing pressure injuries. Interviews with eight residents and staff, as well as record reviews, did not support these claims.
Report Facts
Capacity: 299
Census: 187
Number of allegations: 3
Number of residents interviewed: 8
Number of staff interviewed: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Tao | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation |
| Liyon O'Quinn | Administrator | Facility administrator met during investigation |
Inspection Report
Annual Inspection
Census: 199
Capacity: 299
Deficiencies: 0
Aug 2, 2024
Visit Reason
The inspection was an unannounced required 1-year visit to evaluate compliance with care and regulatory standards using the full Care Compliance and Regulatory Enforcement (CARE) Tools.
Findings
The facility was found to be in compliance with no deficiencies observed. The inspection covered multiple domains including infection control, physical plant safety, staffing, personnel records, client rights, food service, and disaster preparedness. Fire clearance was approved and emergency drills were up to date.
Report Facts
Staff count: 101
Licensed capacity: 285
Licensed capacity: 14
Licensed capacity: 14
Water temperature range: 105
Water temperature range: 120
Emergency drill date: Jun 11, 2024
Fire alarm check date: May 14, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Milca Osorio | Director of Health Services | Met during inspection and involved in facility tour |
| Salimatou Krubally | Assisted Living Supervisor | Present during inspection and exit interview |
| Liyon O'Quinn | Administrator/Facility Director | Facility Administrator with active certificate |
| Fernando Fierros | Supervisor | Named in report as supervisor |
| Sanjay Vaid | Licensing Program Analyst/Evaluator | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 299
Deficiencies: 1
Jul 2, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit to investigate an allegation of unlawful eviction of a resident who was not allowed to return to the facility after hospital discharge.
Findings
The allegation of unlawful eviction was substantiated. The facility staff refused to accept Resident #1 back after discharge on 06/18/2024 without providing a 30-day eviction notice, and there was no documentation indicating the resident required a higher level of care.
Complaint Details
The complaint alleged unlawful eviction of Resident #1 who was not allowed to return after hospital discharge on 06/18/2024. The investigation found the allegation substantiated based on interviews and document review.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility/administrator refusal to accept Resident #1 back to the facility upon discharge from hospital and not providing Resident #1 with the 30 day eviction notice, posing a potential health, safety or personal rights risk to residents in care. | Type B |
Report Facts
Facility capacity: 299
Resident census: 187
Plan of Correction due date: Jul 9, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Named in relation to unlawful eviction allegation and exit interview |
| Nune Margaryan | Licensing Program Analyst | Conducted the complaint investigation |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager overseeing the investigation |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 299
Deficiencies: 1
May 7, 2024
Visit Reason
The visit was a case management follow-up to issue a deficiency after an incident involving the death of Resident #1 on 10/3/23, which was investigated by the Department of Social Services Investigation Branch.
Findings
The investigation found that staff failed to provide proper supervision to Resident #1, who was found injured after a fall and later died. Staff were neglectful in checking on the resident during their shifts, and one staff member had a history of misconduct including sleeping on the job.
Complaint Details
The complaint investigation was substantiated based on the neglectful actions of Staff #1 and Staff #2 towards Resident #1, which led to the resident's injury and subsequent death.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility personnel were not sufficient in numbers and competent to provide necessary services, resulting in failure to provide required supervision to Resident #1, posing an immediate health, safety, and personal rights risk. | Type A |
Report Facts
Civil Penalty: 500
Capacity: 299
Census: 184
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met with Licensing Program Analyst during the inspection and was provided with report and appeal rights. |
| Cynthia D Chan | Licensing Program Analyst | Conducted the case management visit and issued the deficiency. |
| Tony Vasallo | Supervisor | Named as supervisor in the deficiency report. |
| Veronica Padilla | Investigator | Investigated the death of Resident #1. |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 299
Deficiencies: 0
May 7, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation of questionable death of a resident.
Findings
The investigation found that two staff members failed to provide supervision to Resident #1 during their shifts, resulting in the resident falling and sustaining injuries. However, there was no evidence to establish a causal link between the failure to conduct timely rounds and the resident's death, which was ruled an accident by the Medical Examiner. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that Resident #1's death was caused by neglect from Staff #1 who did not check on the resident during the overnight shift. Interviews and record reviews showed staff failed to provide supervision, but no causal link to death was found. The allegation was unsubstantiated.
Report Facts
Staff interviewed: 12
Residents interviewed: 2
Days until resident death: 4
Rooms inspected: 8
Residents' documents requested: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met with Licensing Program Analyst during the investigation |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation visit |
| Veronica Padilla | Investigator | Conducted further investigation including interviews and record reviews |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 299
Deficiencies: 0
Mar 5, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted in response to multiple allegations received on 2024-02-27 regarding staff behavior and facility conditions at Kingsley Manor.
Findings
The investigation included interviews with staff and residents, a tour of the facility, and document reviews. All allegations, including staff not keeping the facility free of obstructions, inappropriate speech, lack of respect and dignity, and failure to safeguard resident property, were found to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint involved allegations that facility staff did not keep the facility free of obstructions, spoke inappropriately to residents, did not treat residents with respect and dignity, and failed to safeguard resident property. After investigation, all allegations were determined to be unsubstantiated.
Report Facts
Staff interviewed: 6
Residents interviewed: 10
Complaint received date: Feb 27, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jose Villalobos | Licensing Program Analyst | Conducted the complaint investigation |
| Liyon O'Quinn | Executive Director | Facility administrator met during investigation |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation |
Inspection Report
Complaint Investigation
Census: 184
Capacity: 299
Deficiencies: 1
Mar 1, 2024
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by multiple allegations received on 06/13/2022 concerning staff misconduct and resident care issues at Kingsley Manor.
Findings
The investigation found most allegations unsubstantiated due to lack of evidence or contradictory statements, except for the allegation that staff did not respond timely to residents' call buttons, which was substantiated due to issues with the facility's pager system causing delayed responses.
Complaint Details
The complaint investigation addressed ten allegations including staff pushing a resident causing a fall, staff threatening residents, staff under the influence of illegal substances, lack of dignity and respect towards residents, resident-to-resident injury, staff breaking resident belongings, unlawful eviction, missing personal belongings, inappropriate staff comments, and delayed staff assistance. All allegations except the delayed response to call buttons were found unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to maintain a signal system that promptly notifies staff of resident calls, resulting in delayed response times posing a health and safety risk. | Type B |
Report Facts
Number of allegations: 10
Number of residents present: 184
Total licensed capacity: 299
Number of staff interviewed: 6
Number of residents interviewed: 5
Number of arrests of resident R1: 5
Plan of Correction due date: Mar 8, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Executive Director | Met with during inspection and named in findings |
| Noemi Galarza | Licensing Program Analyst | Conducted complaint investigation and authored report |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
| S1 | Security Guard/Staff | Named in allegations regarding pushing resident and breaking belongings |
| S4 | Maintenance Director | Named in allegation of threatening resident |
| S5 | Director of Sales and Marketing | Named in allegation of threatening resident |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 299
Deficiencies: 0
Feb 7, 2024
Visit Reason
The inspection was conducted as an unannounced complaint investigation regarding allegations that facility staff were interfering with the resident council.
Findings
The investigation found no evidence that the facility was interfering with the resident council. The issue was related to a corporate policy change on how the Employee Appreciation Fund is handled, which residents and staff were notified about. The allegation was unsubstantiated.
Complaint Details
The complaint alleged that facility staff were interfering with the resident council by changing the policy on distribution of the employee appreciation fund. The investigation included interviews with residents, staff, and corporate representatives. The allegation was found to be unsubstantiated due to lack of evidence.
Report Facts
Residents interviewed: 18
Staff interviewed: 6
Facility capacity: 299
Facility census: 183
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alberto Lopez | Licensing Program Analyst | Conducted the complaint investigation |
| Liyon O'Quinn | Administrator | Facility administrator met during investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw the complaint investigation |
| Jeff Sianko | Chief Operating Officer | Corporate representative who explained policy change |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 299
Deficiencies: 1
Feb 7, 2024
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate allegations that staff were not meeting resident's needs, not safeguarding resident's personal belongings, and harassing a resident.
Findings
The investigation substantiated that staff failed to follow medication management procedures and did not properly care for a resident's diabetic foot wound, posing health and safety risks. However, allegations that staff stole resident belongings and harassed the resident were found to be unsubstantiated due to insufficient evidence.
Complaint Details
The complaint investigation was substantiated for the allegation that staff were not meeting resident's needs, specifically medication management and wound care. The allegations that staff did not safeguard resident's personal belongings and that staff harassed the resident were unsubstantiated due to lack of sufficient evidence.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to have signed, dated physician orders for prescription and nonprescription PRN medications and allowing resident to self-administer medications without physician's order, posing immediate health and safety risk. | Type A |
Report Facts
Capacity: 299
Census: 183
Residents interviewed: 11
Staff interviewed: 6
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Executive Director | Met with during investigation and exit interview |
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation |
| Lisa Hicks | Licensing Program Manager | Oversaw complaint investigation |
| S1 | Director of Resident Services/Staff | Alleged to have harassed resident; allegation unsubstantiated |
| S4 | Caregiver Staff | Alleged to have stolen resident belongings; allegation unsubstantiated |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 299
Deficiencies: 1
Feb 7, 2024
Visit Reason
The inspection visit was conducted as a complaint investigation to review significant changes made by the facility in its policy and plan of operation, specifically regarding the acceptance and handling of 'tips' from the resident's council for the employee appreciation fund.
Findings
The facility made a significant policy change to accept 'tips' from the resident's council for employee appreciation funds, distributing these via payroll and taxing them, without notifying the licensing agency or updating the plan of operation to explain how resident monies would be safeguarded. A deficiency was cited for failure to maintain an updated plan of operation including safeguards for resident cash.
Complaint Details
The visit was complaint-related, investigating the facility's policy change regarding employee appreciation funds. The deficiency was substantiated and cited under section 809D.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to update the plan of operation to include the new policy on accepting 'tips' from the resident's council and did not provide explanation on safeguarding resident monies. | Type B |
Report Facts
Capacity: 299
Census: 181
Plan of Correction Due Date: Feb 21, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met during the inspection and related to findings |
| Lisa Hicks | Supervisor | Named in report as supervisor overseeing the inspection |
| Alberto Lopez | Licensing Evaluator | Conducted the inspection and signed the report |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 299
Deficiencies: 1
Nov 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2021-06-11 regarding allegations of medication mismanagement and lack of dignity and respect towards residents.
Findings
The investigation substantiated the allegation that facility staff mismanaged resident #1's medication, specifically that a medication pill belonging to another resident was dropped in resident #1's room and left there, posing a health and safety risk. The allegation that staff did not treat residents with dignity and respect was unsubstantiated due to lack of sufficient evidence.
Complaint Details
The complaint involved allegations that facility staff mismanaged resident's medication and did not treat residents with dignity and respect. The medication mismanagement allegation was substantiated, while the dignity and respect allegation was unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Staff #1 dropped a medication pill belonging to another resident in resident #1's room and left the medication in the room, posing a health and safety risk. | Type B |
Report Facts
Capacity: 299
Census: 185
Deficiency count: 1
Plan of Correction Due Date: Nov 17, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Angelica Rea | Licensing Program Analyst | Conducted the complaint investigation and issued the report |
| Emyrose Lacuesta | Director of Health Services | Met with Licensing Program Analyst during investigation and exit interview |
| Shaun D. Rushforth | Administrator | Facility administrator named in the report |
| Liyon O'Quinn | Executive Director | Assisted with the investigation visit |
| Staff #1 | Staff member involved in medication mismanagement incident |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 299
Deficiencies: 0
Nov 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that the facility would not accept monthly rent payments from a resident when the resident attempted to pay monthly rent.
Findings
The investigation found that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation did or did not occur, resulting in the allegation being unsubstantiated. Staff interviews and document reviews confirmed an eviction notice and unlawful detainer were issued, and the facility was legally advised not to accept payments from the resident.
Complaint Details
The complaint alleged that the facility would not accept monthly rent payments from a resident. The allegation was unsubstantiated after investigation. It was confirmed that an eviction notice and unlawful detainer were issued to the resident, and the facility was legally advised not to accept payments. The resident wanted the facility to obtain payment from the Assisted Living Waiver program, but that program does not cover rent or board and care fees.
Report Facts
Facility capacity: 299
Resident census: 185
Staff interviewed: 4
Collection letters issued: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emyrose LaCuesta | Director of Health Services | Met with during investigation and exit interview |
| Valeria Maldonado | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Annual Inspection
Census: 179
Capacity: 299
Deficiencies: 0
Jul 20, 2023
Visit Reason
This is a follow up annual visit to continue the annual inspection that was first conducted on 7/11/2023.
Findings
Personnel records and staff training were reviewed and found to be in compliance, including criminal background clearance and required certifications. Health-related services such as medication administration were properly managed, and disaster preparedness measures including emergency plans and drills were observed.
Report Facts
Staff files reviewed: 9
Resident medication records reviewed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Administrator certificate active and effective through 10/11/2023 |
| Emyrose La Cresta | Director of Health Services | Met with during inspection |
Inspection Report
Annual Inspection
Census: 179
Capacity: 299
Deficiencies: 1
Jul 11, 2023
Visit Reason
An unannounced Required 1 Year annual inspection visit was conducted using the full Care Compliance and Regulatory Enforcement (CARE) Tools to evaluate compliance with regulatory requirements.
Findings
The inspection covered 12 CARE tool domains including infection control, physical plant safety, staffing, personnel records, resident rights, food service, and incident reports. A deficiency was found related to water temperature in two restrooms exceeding the allowed range, which was corrected during the visit. The annual inspection was not completed and will be resumed at a later date.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Water temperature in two restrooms within the White House exceeded the allowed range of 105-120 degrees Fahrenheit, measuring 140 and 126 degrees Fahrenheit respectively. | Type A |
Report Facts
Residents present: 179
Total licensed capacity: 299
Staff members: 101
Deficiencies cited: 1
Fire clearance capacity: 299
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emyrose La Cresta | Director of Health Services | Met during inspection and involved in discussion of visit purpose |
| Liyon O'Quinn | Administrator | Facility administrator present during inspection and responsible for correction of deficiency |
| Erik Zaragoza | Licensing Program Analyst | Conducted the inspection |
| David Sicairos | Supervisor | Supervisor overseeing the inspection process |
Inspection Report
Complaint Investigation
Census: 182
Capacity: 299
Deficiencies: 0
May 17, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by an allegation that staff were not preventing a resident from being financially abused by another resident.
Findings
The investigation found insufficient evidence to substantiate the allegation of financial abuse between residents. Interviews with residents, staff, and family members, as well as document reviews, indicated that the alleged financial transfer had not occurred and the resident denied abuse. The allegation was determined to be unsubstantiated.
Complaint Details
The complaint alleged that resident (R1) was being financially exploited by resident (R2), who requested a transfer of stock shares owned by R1. The investigation included interviews with 16 residents, 4 staff, private caregiver, and family members, as well as review of resident files and physician reports. Resident (R1) denied abuse and was oriented to person, place, and situation. Resident (R2) denied abuse and stated the transfer was a mutual decision. No financial interests had been transferred due to lack of authorization. The allegation was unsubstantiated due to insufficient evidence.
Report Facts
Residents interviewed: 16
Staff interviewed: 4
Facility capacity: 299
Facility census: 182
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Noemi Galarza | Licensing Program Analyst | Conducted the complaint investigation and subsequent visit |
| Emyrose LaCuesta | Director of Health Services | Facility representative met during the investigation and exit interview |
| Lisa Hicks | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 299
Deficiencies: 0
Apr 24, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff were not following a resident's dietary needs.
Findings
The investigation found that residents and staff reported no ongoing issues with dietary needs. The facility provides special menus and replacement meals as needed. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged staff were not following a resident's dietary needs. After interviews with residents and staff, and a tour of the kitchen and dining areas, the allegation was found unsubstantiated.
Report Facts
Capacity: 299
Census: 178
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Liyon O'Quinn | Executive Director | Facility administrator met during investigation and exit interview |
| Wei Siew Ho | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 178
Capacity: 299
Deficiencies: 0
Apr 14, 2023
Visit Reason
The visit was an unannounced complaint investigation conducted in response to allegations received on 04/10/2023 regarding staff behavior and resident care at Kingsley Manor.
Findings
The investigation found that staff communicated politely and professionally with residents, treated residents with dignity and respect, and provided a comfortable environment. Interviews with residents and staff did not substantiate the allegations.
Complaint Details
The complaint involved allegations that staff spoke inappropriately to residents, failed to treat residents with dignity and respect, and failed to provide a comfortable environment. The investigation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Residents interviewed: 12
Staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met with during the investigation and named in findings |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on the report |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 299
Deficiencies: 0
Mar 27, 2023
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that the facility was financially abusing a resident while in care.
Findings
The investigation included interviews with the resident, staff, and administrator, as well as a review of relevant documents. It was found that the resident spent his own money gambling and the facility did not have access to his funds. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged financial abuse of a resident. The Power of Attorney reported withdrawals over $1250 in two months, but stated the facility did not do any wrongdoing. The resident confirmed the facility did not touch his money and spends money at casinos. The allegation was unsubstantiated.
Report Facts
Amount withdrawn: 1250
Census: 181
Total capacity: 299
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Liyon O'Quinn | Executive Director | Facility administrator interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 299
Deficiencies: 1
Mar 23, 2023
Visit Reason
The inspection was an unannounced complaint investigation triggered by allegations that the facility elevators were in disrepair and that the facility did not have heat.
Findings
The investigation substantiated that one elevator in the Leitzell Hall building was down for a couple of months but has since been repaired and is now working properly. The allegation regarding lack of heat was unsubstantiated as the facility's heating system was found to be functioning properly with residents reporting comfortable room temperatures.
Complaint Details
The complaint investigation was substantiated for the elevator disrepair allegation and unsubstantiated for the heating allegation. The elevator was down due to difficulty obtaining parts but was repaired prior to the inspection. The heating system was functioning properly with maintenance staff monitoring circuit breakers and residents reporting adequate heat.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The licensee did not ensure that both elevators in the Leitzell Hall building were working properly, posing a potential health, safety, and personal rights risk to residents. | Type B |
Report Facts
Capacity: 299
Census: 181
Deficiencies cited: 1
Plan of Correction Due Date: Mar 30, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met with during investigation and provided information on elevator and heating issues |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
| Tena Herrera | Licensing Program Analyst | Assisted in conducting the complaint investigation |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 299
Deficiencies: 0
Mar 7, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident sustaining an injury while in care, a resident threatening the safety of others, and staff not meeting qualifications for their job duties.
Findings
The investigation found insufficient evidence to substantiate the allegations. The resident injury allegation was unsubstantiated despite documentation of a fall and hospitalization. The allegation of a resident threatening others was unsubstantiated after review of incident reports and resident removal. The allegation that staff did not meet qualifications was also unsubstantiated based on interviews and training documentation.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included a resident injury from a fall, a resident exhibiting threatening behavior and intoxication, and staff performing duties without proper qualifications. Investigators reviewed incident reports, interviewed staff and residents, and reviewed training and physician reports. No preponderance of evidence was found to prove violations.
Report Facts
Residents interviewed: 10
Staff interviewed: 7
Incident reports reviewed: 6
Training days: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation and interviews |
| Liyon O'Quinn | Executive Director | Facility administrator interviewed during investigation |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation report |
Inspection Report
Complaint Investigation
Census: 180
Capacity: 299
Deficiencies: 1
Feb 9, 2023
Visit Reason
The inspection was an unannounced complaint investigation visit regarding allegations that the facility had bed bugs, was not clean and sanitary at all times, resident rooms were malodorous, and the facility was not meeting residents' dietary needs.
Findings
The investigation substantiated the allegation of bed bugs in several rooms based on observations, resident and staff interviews, and pest control reports. The allegations regarding cleanliness, odors, and dietary needs were found to be unsubstantiated based on interviews and observations. A deficiency was cited for failure to maintain the facility free of bed bugs, which was cleared during the visit.
Complaint Details
The complaint investigation was substantiated for the allegation of bed bugs found in rooms #200, 201, 203, 328, 329, and others. Interviews with residents and staff revealed mixed observations, with some confirming bed bugs and treatment provided. Pest control service reports confirmed bed bug activity. Other allegations about cleanliness, odors, and dietary needs were unsubstantiated.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| The facility was not clean, safe, sanitary and in good repair at all times due to bed bug infestation. | Type B |
Report Facts
Capacity: 299
Census: 180
Deficiencies cited: 1
Pest control service report dates: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Mary G Flores | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation report |
| Liyon O'Quinn | Administrator | Facility administrator interviewed during the investigation |
Inspection Report
Annual Inspection
Census: 183
Capacity: 299
Deficiencies: 0
Feb 7, 2023
Visit Reason
An unannounced annual inspection was conducted to evaluate the facility's compliance with licensing and regulatory requirements.
Findings
The facility was found to be in compliance with all applicable regulations, including fire safety, staffing, medication management, and environmental conditions. No deficiencies were observed during the visit.
Report Facts
Licensed capacity: 299
Census: 183
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Emyrose Lacuesta | Director of Health Services | Met with Licensing Program Analyst during inspection and received the report |
Inspection Report
Complaint Investigation
Census: 183
Capacity: 299
Deficiencies: 0
Feb 7, 2023
Visit Reason
The visit was an unannounced complaint investigation triggered by allegations received on 2022-11-17 regarding staff assistance to residents, pest control, and COVID-19 protocol adherence.
Findings
The investigation found no preponderance of evidence to substantiate the allegations. Staff were reported to assist residents appropriately, pest control measures were in place and effective, and COVID-19 protocols were generally followed with some resident noncompliance.
Complaint Details
The complaint included allegations that staff did not provide proper assistance to a resident, were not mitigating the spread of pests, and were not following COVID-19 protocols. The investigation included interviews with staff, residents, pest control technician, and public health nurse. The allegations were determined to be unsubstantiated.
Report Facts
Capacity: 299
Census: 183
Number of residents interviewed: 10
Number of staff interviewed: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Executive Director | Met with Licensing Program Analyst during investigation and provided information regarding allegations |
| Cynthia D Chan | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Tony Vasallo | Licensing Program Manager | Named as Licensing Program Manager on report |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 299
Deficiencies: 1
Feb 3, 2023
Visit Reason
Unannounced complaint investigation conducted due to allegations that the facility was not kept free of insects and had bed bugs.
Findings
The investigation substantiated the allegations that bed bugs and roaches were present in multiple resident rooms, confirmed by staff and residents interviews and pest control records. The facility was found to be in violation of maintenance and operation requirements for cleanliness and pest control.
Complaint Details
The complaint was substantiated based on interviews with staff and residents and review of pest control records showing bed bugs and roaches in multiple resident rooms. Bed bugs were found on or about 08/31/2020 and 09/01/2020, and roaches were found on 09/17/2020.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Facility failed to maintain a clean, safe, sanitary environment free of bed bugs and roaches, posing a potential risk to residents' health and safety. | Type B |
Report Facts
Capacity: 299
Census: 190
Deficiency Type: 1
Plan of Correction Due Date: Feb 10, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Tony Vasallo | Licensing Program Manager | Oversaw the complaint investigation |
| Liyon O'Quinn | Executive Director | Facility representative met during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 299
Deficiencies: 0
Feb 3, 2023
Visit Reason
The inspection was an unannounced complaint investigation regarding an allegation that the facility is in disrepair with a leaking air conditioner.
Findings
The investigation found that five out of five staff denied the allegation and four out of four residents reported no issues with their air conditioning units. Observations confirmed that resident window air conditioning units were operational. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged the facility had not repaired a leaking air conditioner. The allegation was unsubstantiated after investigation.
Report Facts
Capacity: 299
Census: 190
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kimberly Ramirez | Licensing Program Analyst | Conducted the complaint investigation |
| Tony Vasallo | Licensing Program Manager | Named in report as Licensing Program Manager |
| Liyon O'Quinn | Executive Director | Met with Licensing Program Analyst during investigation and exit interview |
Inspection Report
Complaint Investigation
Census: 185
Capacity: 299
Deficiencies: 0
Jan 24, 2023
Visit Reason
The inspection was an unannounced complaint investigation conducted in response to allegations received on 12/31/2020 regarding staff failing to return residents' personal belongings, treating residents with dignity and respect, engaging in verbal altercations, and failing to meet residents' needs.
Findings
The investigation included interviews with staff and residents, record reviews, and a facility tour. All allegations were found to be unsubstantiated as interviews and evidence did not corroborate the complaints.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included staff failing to return resident's personal belongings, treating residents without dignity and respect, engaging in verbal altercations, and failing to meet residents' needs. Interviews with seven residents and eight staff members did not corroborate any allegations.
Report Facts
Capacity: 299
Census: 185
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Tao | Licensing Program Analyst | Conducted the complaint investigation |
| Fernando Fierros | Licensing Program Manager | Oversaw the complaint investigation |
| Liyon O'Quinn | Administrator | Facility administrator met during the investigation |
Inspection Report
Complaint Investigation
Census: 187
Capacity: 299
Deficiencies: 0
Nov 30, 2022
Visit Reason
The visit was an unannounced case management inspection conducted due to an incident reported to the Community Care Licensing Division on 11/21/2022 involving a resident fall.
Findings
The investigation found that Resident #1 had an accidental ground level fall resulting in fractures but no signs of neglect or lack of supervision were identified. No deficiencies were issued.
Complaint Details
The complaint involved a fall incident of Resident #1 on 11/20/2022, with injuries including a fractured left knee and right wrist. The complaint was investigated and found to be unsubstantiated with no neglect or lack of supervision.
Report Facts
Incident report date: Nov 21, 2022
Incident date: Nov 20, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Administrator | Met during visit and provided information about Resident #1 |
| Emyrose Lacuesta | Director of Health Services | Submitted the incident report and provided details about Resident #1's condition |
| Bennette Pena | Licensing Program Analyst | Conducted the unannounced case management visit |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 299
Deficiencies: 0
Nov 16, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation that staff were not meeting residents' showering needs.
Findings
The investigation found that staff assisted the resident with all showering needs on 11/13/2022 and that the resident prefers showering once a week on Sundays. A meeting was scheduled to discuss the matter further. The allegation was determined to be unsubstantiated due to lack of preponderance of evidence.
Complaint Details
The complaint alleged that staff were not meeting residents' showering needs. The investigation included interviews with the resident, staff, and administrator, and review of relevant schedules and agreements. The allegation was found unsubstantiated.
Report Facts
Capacity: 299
Census: 191
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Glenn Trueman | Licensing Program Analyst | Conducted the complaint investigation |
| Liyon O'Quinn | Executive Director | Facility administrator interviewed during investigation |
| Wei Siew Ho | Licensing Program Manager | Named in report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 299
Deficiencies: 0
Nov 8, 2022
Visit Reason
An unannounced complaint investigation was conducted regarding an allegation of illegal eviction of a resident at Kingsley Manor.
Findings
The investigation found that the eviction notices issued to the resident were lawful and in compliance with regulations. Despite the resident's claim, there was insufficient evidence to substantiate the allegation, resulting in an unsubstantiated finding.
Complaint Details
The complaint alleged illegal eviction of resident #1. Interviews with residents and staff, as well as document reviews, showed that eviction procedures followed required regulations and that the resident had not complied with payment requests since November 2021. The allegation was unsubstantiated due to lack of preponderance of evidence.
Report Facts
Capacity: 299
Census: 191
Eviction notice date: Oct 5, 2022
Complaint received date: Nov 1, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Bonnie Tao | Licensing Program Analyst | Conducted the complaint investigation |
| Liyon O'Quinn | Executive Director | Facility representative interviewed during investigation |
| Fernando Fierros | Licensing Program Manager | Named in report header and signature |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 299
Deficiencies: 1
Oct 18, 2022
Visit Reason
An unannounced complaint investigation was conducted to determine the validity of the allegation that staff do not assist a resident (R1) with showering.
Findings
The investigation found that staff had not assisted R1 in transferring from the wheelchair to the shower since 09/04/2022 due to a staff injury. The facility's Licensed Vocational Nurse recommended R1 move to a higher level of care. Seven out of eight residents interviewed did not corroborate the allegation. The physician report indicated R1 is ambulatory and capable of self-care, but R1 had not received shower assistance as required. The allegation was substantiated.
Complaint Details
The complaint alleged that staff do not assist resident R1 with showering. The allegation was substantiated based on interviews and records reviewed. Staff had not assisted R1 with showering since 09/04/2022. The facility recommended R1 move to a skilled nursing section for higher level care. Seven of eight residents interviewed did not corroborate the allegation. The physician report indicated R1 is ambulatory and capable of self-care. The preponderance of evidence standard was met.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met by evidence of R1 not receiving shower assistance. | Type A |
Report Facts
Census: 191
Total Capacity: 299
Deficiencies cited: 1
Plan of Correction Due Date: Oct 19, 2022
Physician report date: Jun 10, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lyon O'Quinn | Executive Director | Met with Licensing Program Analyst during investigation and involved in findings |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 191
Capacity: 299
Deficiencies: 1
Oct 7, 2022
Visit Reason
An unannounced complaint investigation was conducted to determine the validity of an allegation that staff do not assist a resident (R1) with showering.
Findings
The investigation found that staff have not assisted R1 in transferring from the wheelchair to the shower since 09/04/2022 due to a staff injury. The facility's Licensed Vocational Nurse recommended R1 move to a higher level of care. Seven out of eight other residents reported receiving shower assistance. The allegation was substantiated based on interviews and record reviews.
Complaint Details
The complaint alleged that staff do not assist resident R1 with showering. The allegation was substantiated after investigation, with evidence showing R1 has not received shower assistance since 09/04/2022.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Basic Services. Personal assistance and care as needed by the resident and as indicated in the pre-admission appraisal, with those activities of daily living such as dressing, eating, bathing and assistance with taking prescribed medications, as specified in Section 87608, Postural Supports. This requirement was not met by evidence of R1 not receiving assistance with showering which poses a potential risk to health, safety, or personal rights. | Type B |
Report Facts
Capacity: 299
Census: 191
Deficiency count: 1
Plan of Correction Due Date: Nov 4, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Luis Mora | Licensing Program Analyst | Conducted the complaint investigation and authored the report |
| Lyon O'Quinn | Executive Director | Met with Licensing Program Analyst during investigation and involved in interviews |
| Wei Siew Ho | Licensing Program Manager | Oversaw the complaint investigation process |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 299
Deficiencies: 0
Sep 27, 2022
Visit Reason
The visit was an unannounced complaint investigation conducted to address allegations that facility staff did not assist a resident with showering needs and did not ensure that the resident was taking medications as prescribed.
Findings
The investigation found that Resident #1 was independent in self-care and medication management, refused facility care services, and had left the facility following hospitalization. There was insufficient evidence to substantiate the allegations, and both were found to be unsubstantiated.
Complaint Details
The complaint investigation was unsubstantiated. Allegations included neglect/lack of care regarding assistance with showering and medication administration. Interviews, record reviews, and evidence showed no preponderance to prove the alleged violations occurred.
Report Facts
Capacity: 299
Census: 190
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Ceniceros | Licensing Program Analyst | Conducted the complaint investigation visit and interviews |
| Liyon O'Quinn | Executive Director | Met with Licensing Program Analyst during the investigation |
| Shaun D. Rushforth | Administrator | Former Administrator mentioned in the investigation |
| Araceli Ramirez | Licensing Program Manager | Named in the report as Licensing Program Manager |
Inspection Report
Complaint Investigation
Census: 190
Capacity: 299
Deficiencies: 0
Sep 26, 2022
Visit Reason
The visit was an unannounced case management inspection to gather information regarding a reported incident where Resident #1 alleged someone touched their private part, as per SOC 341 faxed on 08/22/22.
Findings
Interviews and investigation revealed that Resident #1 did not remember the alleged incident and no other allegations were reported. The Licensing Program Analyst found no deficiencies cited during the visit.
Complaint Details
The complaint involved an allegation by Resident #1 that someone entered their room and touched their private part, but the resident could not identify the person or the time of the incident. Subsequent interviews indicated a misunderstanding and no substantiated memory of the event by the resident.
Report Facts
Census: 190
Total Capacity: 299
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jewel Baptiste | Licensing Program Analyst | Conducted the unannounced case management inspection |
| Qunn Liyon | Executive Director | Met with Licensing Program Analyst during inspection |
| Emyrose Lacuesta | Director of Health Services | Met with Licensing Program Analyst and received report copy |
| Lisa Hicks | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 193
Capacity: 299
Deficiencies: 0
Jul 1, 2022
Visit Reason
An unannounced Case Management - Incident visit was conducted to obtain information on the death of a resident that occurred on June 26, 2022.
Findings
The resident was found deceased after falling from the 5th floor balcony. The facility provided notification to the licensing division and relevant documents were obtained for review.
Complaint Details
The visit was triggered by the incident and death of a resident on June 26, 2022. The resident was pronounced dead at the scene after falling from the 5th floor balcony. The facility was instructed to submit the Death Certificate and Coroner's report.
Report Facts
Facility capacity: 299
Resident census: 193
Balcony railing height: 36
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Marilou Mendoza | Senior Executive Assistant | Met during the visit and participated in the exit interview |
| Liyon O'Quinn | Executive Director | Informed telephonically about the purpose of the visit |
| Noemi Galarza | Licensing Program Analyst | Conducted the unannounced Case Management - Incident visit |
Inspection Report
Complaint Investigation
Census: 198
Capacity: 299
Deficiencies: 1
Jun 14, 2022
Visit Reason
An unannounced visit was made for the purpose of an unrelated complaint investigation regarding failure to report an active COVID-19 case at the facility.
Findings
The facility had one active COVID-19 case that was not reported to Community Care Licensing as required by regulation, resulting in a cited deficiency for failure to meet reporting requirements.
Complaint Details
The visit was triggered by a complaint investigation control # 28-AS-20220613092610. The deficiency was substantiated as the facility did not report a COVID-19 positive resident (R1) diagnosed on June 9, 2022.
Severity Breakdown
Type B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to report an active COVID-19 case to Community Care Licensing within 24 hours as required by Title 22, Division 6, Chapter 8; 87211 Reporting Requirements. | Type B |
Report Facts
Active COVID-19 cases: 1
Deficiency count: 1
Plan of Correction due date: Jun 21, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quin | Executive Director | Met with Licensing Program Analyst during the visit and discussed the purpose of the visit |
| Noemi Galarza | Licensing Program Analyst | Conducted the unannounced complaint investigation visit |
| Lisa Hicks | Supervisor | Supervisor overseeing the licensing evaluation |
Inspection Report
Complaint Investigation
Census: 197
Capacity: 299
Deficiencies: 2
May 16, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations including a resident threatening another resident, calling another resident names, and a resident obtaining bleach.
Findings
The investigation substantiated that Resident 4 (R4) threatened and harassed Resident 6 (R6), including invading personal space and making derogatory comments. R4 also poured bleach on R6's door, posing a health and safety risk. Staff and residents reported fear and intimidation caused by R4's behavior, and the facility relocated R6 for safety.
Complaint Details
The complaint investigation was substantiated. Allegations included a resident threatening another resident, calling names, and obtaining bleach. Evidence showed R4 threatened and harassed R6, poured bleach on R6's door, and caused fear among residents and staff.
Severity Breakdown
Type A: 1
Type B: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Storage space for disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients was not secure, evidenced by R4 pouring bleach on R6's door. | Type A |
| Failure to accord dignity in personal relationships with staff, residents, and others, evidenced by R4 screaming at, intimidating, and harassing Resident 6. | Type B |
Report Facts
Facility capacity: 299
Resident census: 197
Deficiency due date: May 17, 2022
Deficiency due date: May 23, 2022
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Executive Director | Interviewed regarding allegations and findings |
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation |
| Stefanie Coronel | Licensing Program Manager | Oversaw the complaint investigation |
| Randy Herzig | Divisional Vice President | Interviewed during investigation |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 299
Deficiencies: 0
May 12, 2022
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by allegations that staff did not prevent a resident from engaging in inappropriate behaviors and failed to provide a safe environment for residents in care.
Findings
The investigation found that although a resident (R4) exhibited aggressive and inappropriate behaviors causing concern among residents, staff took actions to redirect and keep residents safe, including calling police when necessary. Interviews with staff, residents, and family members indicated that the facility provides a safe environment and prevents inappropriate behaviors. There was insufficient evidence to substantiate the allegations, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint involved allegations that staff failed to prevent a resident from engaging in inappropriate behaviors and failed to provide a safe environment. The resident was physically violent, damaged property, and caused distress among other residents. Staff and management reported efforts to manage the resident's behavior, including police involvement and attempts to evict the resident. Interviews with staff, residents, and family members supported that staff acted appropriately. The complaint was unsubstantiated due to lack of sufficient evidence.
Report Facts
Capacity: 299
Census: 194
Residents interviewed: 19
Staff interviewed: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Liyon O'Quinn | Executive Director | Interviewed regarding complaint and facility operations |
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation |
| Randy Herzig | Divisional Vice President | Interviewed regarding facility safety and resident rights |
Inspection Report
Complaint Investigation
Census: 181
Capacity: 299
Deficiencies: 0
Dec 17, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by an allegation that a resident was raped by a staff member.
Findings
The investigation included interviews with residents, family members, caregivers, and review of hospital medical records. There was insufficient evidence to substantiate the allegation, and the complaint was determined to be unsubstantiated.
Complaint Details
The complaint alleged that a resident was raped by a staff member. Interviews revealed cognitive impairment of the resident and no corroborating evidence was found. Family members and staff denied neglect or abuse. Hospital records showed no trauma or complaints. The allegation was unsubstantiated due to lack of evidence.
Report Facts
Capacity: 299
Census: 181
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Alma Gonzalez | Licensing Program Analyst | Conducted the complaint investigation visit and delivered findings |
| Liyon O'Quinn | Executive Director | Met with Licensing Program Analyst during visit and received report |
| Laura Garcia | Investigator | Conducted interviews and investigation for the complaint |
| Randy Herzig | Facility Administrator | Interviewed during investigation |
| Gemma DeLeon | Facility Caregiver | Interviewed during investigation |
Inspection Report
Routine
Census: 194
Capacity: 299
Deficiencies: 0
Aug 10, 2021
Visit Reason
An unannounced Required-1 year visit focusing on COVID-19 Infection Control Practices was conducted to evaluate compliance with infection control regulations.
Findings
The facility was inspected and toured with no deficiencies observed. COVID-19 infection control practices, signage, PPE supply, social distancing, and food supplies were all found adequate and in compliance with regulations.
Report Facts
Residents medication supply reviewed: 15
PPE supply duration: 90
Food supply duration - perishable: 2
Food supply duration - non-perishable: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Randy Herzig | Administrator | Met during inspection and exit interview |
| Alma Gonzalez | Licensing Program Analyst | Conducted the inspection |
Inspection Report
Complaint Investigation
Census: 194
Capacity: 299
Deficiencies: 1
Jun 21, 2021
Visit Reason
The inspection was an unannounced complaint investigation visit triggered by a complaint received on 10/15/2020 alleging that the facility had vermin.
Findings
The investigation substantiated the allegation of vermin presence, specifically rats and cockroaches in the facility kitchen, which led to the kitchen being shut down for 48 hours. Environmental Health Specialist Larry Regalado observed numerous rat droppings and dead cockroaches, and the kitchen was given a Facility Status grade B with a score of 82. The kitchen was cleared and allowed to resume operation after sanitation and elimination of the infestation.
Complaint Details
The complaint was substantiated based on evidence including interviews with Executive Director Ted Maneerod, Environmental Health Specialist Larry Regalado, and review of reports. The facility kitchen was found to have rat droppings and dead cockroaches, leading to a 48-hour closure of kitchen operations.
Severity Breakdown
Type A: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| General Food Service Requirements. All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects. LPA observed 2 rat traps in kitchen area. Facility had rat droppings and dead cockroaches in different areas of the kitchen, resulting in suspension of kitchen operations for 48 hours. | Type A |
Report Facts
Rat droppings observed: 40
Rat droppings observed: 30
Rat droppings observed: 12
Rat droppings observed: 15
Kitchen closure duration: 48
Facility capacity: 299
Facility census: 194
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ted Maneerod | Executive Director | Interviewed regarding vermin complaint and kitchen closure. |
| Alma Gonzalez | Licensing Program Analyst | Conducted complaint investigation and inspection. |
| Larry Regalado | Environmental Health Specialist | Conducted environmental health inspections and observed vermin evidence. |
| Rebecca Orendain | Licensing Program Manager | Named as Licensing Program Manager on report. |
Inspection Report
Complaint Investigation
Census: 209
Capacity: 299
Deficiencies: 0
Nov 2, 2020
Visit Reason
The visit was an unannounced complaint investigation conducted to investigate an allegation that staff did not protect a resident from financial abuse.
Findings
The investigation included interviews with residents, caregivers, and the administrator, as well as a review of relevant logs and policies. All residents denied unauthorized withdrawals or transfers of money, and no evidence was found to substantiate the allegation. The complaint was determined to be unsubstantiated with no deficiencies cited.
Complaint Details
The complaint alleged that staff did not protect a resident from financial abuse. The investigation found no preponderance of evidence to prove the alleged violation occurred, resulting in an unsubstantiated finding.
Report Facts
Capacity: 299
Census: 209
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Renee Arterberry | Licensing Program Analyst | Conducted the complaint follow-up visit and investigation |
| Shaun D. Rushforth | Administrator | Facility administrator mentioned in the investigation |
| Manny Ross | Assistant Administrator | Met with the evaluator during the investigation |
| Wei Siew Ho | Supervisor | Supervisor overseeing the investigation |
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