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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609302
Report Date: 10/27/2022
Date Signed: 10/27/2022 12:14:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/27/2022 12:14 PM - It Cannot Be Edited
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 INCFACILITY NUMBER:
197609302
ADMINISTRATOR:TASHA KANALEYFACILITY TYPE:
735
ADDRESS:1859 UPPER COURTTELEPHONE:
(323) 635-8150
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 4DATE:
10/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Adetola OrenowoTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA was greeted by staff and LPA’s temperature was taken. At 11:20 a.m a physical tour of the facility was conducted and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked cabinet. Dual Smoke detectors/Carbon monoxide detectors are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:57 a.m. and appear to be functional. Facility has multiple fire extinguisher that are full charged with a purchase date of 06/15/22. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 72.0 F. There is a closet in where the laundry and chemicals are stored. This door is locked and inaccessible to clients. Clients Rooms: Facility has five (5) bedrooms which of four (4) are designated for client use. All five (5) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the clients. Towels are not shared. All rooms have adequate lighting. Bathrooms: There are two (2) bathrooms in the facility designated for client's use. LPA observed all bathrooms to have grab bars. The hot water was tested and measured at 116.4 F. All trash cans located in the bathrooms had tight fitting lids.

(Continue on 809-C)

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/27/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 10/27/2022
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Garage: There is an attached garage that is accessible through the staff rooms. This area is used for additional storage for items such as PPE and dry goods. Garage contains a deep freezer that is used for additional food storage. Outside Area: LPA observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water.

No deficiencies cited at this time. Exit interview conducted. Report signed and delivered

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022
LIC809 (FAS) - (06/04)
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