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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:23:49 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/24/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220124170445
FACILITY NAME:KELLY HOUSE INCFACILITY NUMBER:
197609302
ADMINISTRATOR:TASHA KANALEYFACILITY TYPE:
735
ADDRESS:1859 UPPER COURTTELEPHONE:
(323) 635-8150
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY:6CENSUS: 5DATE:
04/05/2022
UNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH:Tekoa Huey, Co-AdministratorTIME COMPLETED:
01:35 PM
ALLEGATION(S):
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Staff caused injury to resident.

Staff encouraged resident to self harm.
INVESTIGATION FINDINGS:
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At 12:25 pm Licensing Program Analyst (LPA) Shira Stamps arrived at the facility mentioned above to conduct a subsequent complaint visit. LPA was greeted at the door by a caregiver. The caregiver contacted the Co-Administrator Tekoa Huey, over the phone. The Administrator arrived at 1:00 pm, and LPA explained the reason for the visit.

Allegation: Staff caused injury to resident.

Based on interviews, two (2) out of the three (3) residents interviewed indicated staff have put them in a choke hold. One (1) out of three (3) residents indicated they have never seen staff choke or injure a resident. Interviews with five (5) out of five (5) staff members indicated they have never seen a staff member choke or injure a resident. Based on interviews six(6) out of eight (8) individuals interviewed indicated staff have never caused injury to residents in care. Therefore, this allegation is deemed unsubstantiated.
CONTINUED...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20220124170445
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KELLY HOUSE INC
FACILITY NUMBER: 197609302
VISIT DATE: 04/05/2022
NARRATIVE
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Allegation: Staff encouraged resident to self harm.

LPA interviewed three (3) out of four (4) residents, and five (5) out of five (5) staff members. Based on the interviews five (5) out of (5) staff members indicated they have never heard a staff member tell a resident to harm themselves, and two (2) out of three (3) residents interviewed indicated staff have never encouraged residents to harm themselves. Therefore, based on interviews this allegation is deemed unsubstantiated.

Exit interview conducted and report delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2