197609302-6-28-2022-31-AS-NGID-CGFVEM-20220718162234

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:30:36 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
04/11/2022 and conducted by Evaluator Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220411095356

FACILITY NAME:	KELLY HOUSE INC		FACILITY NUMBER:	197609302
ADMINISTRATOR:	TASHA KANALEY		FACILITY TYPE:	735
ADDRESS:	1859 UPPER COURT		TELEPHONE:	(323) 635-8150
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93550
CAPACITY:	6	CENSUS: 4	DATE:	06/28/2022
		UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Adetola Orenowo		TIME COMPLETED:	01:45 PM

ALLEGATION(S):

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Staff inappropriately restrained resident.
Staff does not take resident outside of the home.

INVESTIGATION FINDINGS:

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At 1:00 p.m Licensing Program Analysts (LPAs) Joscelyn Martinez and Wendell Smith conducted a subsequent complaint visit to deliver the findings of the above allegations. Entrance interview conducted with the Administrator.

On 4/19/22 LPA Shira Stamps initiated the complaint investigation. At approximately 10:05 am, LPA conducted a physical plant tour. At 11:10 am LPA completed a record review of the client’s files and collected copies. From 10:07-11:07 am LPA began interviews with three (3) out of (3) staff members and two (2) out of four (4) clients. It is alleged that staff inappropriately restrained a client.

The staff members indicated the client was not restrained at any time during the alleged incident, and that they used verbal redirection so that C1 would go back into their room. Two (2) out of the three (3) staff members interviewed witnessed the incident that occurred on 4/09/22. Allegedly an incident occurred between two other clients, where one client was attempting to share their medications with another client.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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 31-AS-20220411095356

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: 06/28/2022

NARRATIVE

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The client attempted to go to the bathroom after medication distributions to hide the medications for another client, and staff formed a human barrier in the hallway to prevent the client from hiding the medications. C1 came out of their room screaming and yelling at staff, and spit in a staff member’s face. Staff then verbally redirected C1 back to their room. The clients that were interviewed were not able to indicate when and what happened during the alleged incident. It was found that staff did not inappropriately restrain the client, therefore based on interviews the allegation, “Staff inappropriately restrained resident, “ is deemed unsubstantiated.

Allegation: Staff does not take resident outside of the home.

Interviews with clients indicated staff take clients out of the home to go grocery shopping, the mall, and to get food at least one time a week. It was alleged that staff do not take clients out of the home. Interviews with staff indicated clients go outside of the home three to four times a week. Staff indicated the only client that refuses to go out is C1. LPA Stamps reviewed the outing log that showed documentation of C1’s refusal to go out on outings. Interviews and document reviews indicate staff offer to take clients out of the home, but C1 refuses, therefore based on interviews and document review the allegation, “Staff does not take resident outside of the home,” is deemed unsubstantiated.

Appeal rights issued. Exit interview conducted and Report Delivered to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC9099 (FAS) - (06/04)

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