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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609302
Report Date: 10/04/2024
Date Signed: 10/04/2024 02:42:49 PM

Document Has Been Signed on 10/04/2024 02:42 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KELLY HOUSE INCFACILITY NUMBER:
197609302
ADMINISTRATOR/
DIRECTOR:		TEKOA HUEYFACILITY TYPE:
735
ADDRESS:1859 UPPER COURTTELEPHONE:
(323) 635-8150
CITY:PALMDALESTATE: CAZIP CODE:
93550
CAPACITY: 6CENSUS: 4DATE:
10/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:30 AM
MET WITH:Rasheed Ade OrenowoTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 10/04/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the facility manager. LPA Spaeth stated the purpose of the visit was to conduct an annual inspection. The facility is licensed as an adult residential facility to serve six ambulatory clients.

LPA and the facility manager began the tour of the facility at 8:35 am until 9:10 am. LPA observed the following:

Living Room– LPA Spaeth observed the living room contained comfortable seating and a television.

Family Room - LPA Spaeth observed comfortable seating and a television.

Kitchen - The kitchen contains a kitchen table and chairs. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The knives were locked in a kitchen cabinet. The fire extinguisher is located in the kitchen.

Hallway Closet - The closet was locked and contained the client medication, first aid kit and client records..

Laundry area - The laundry area was locked and contained laundry soap, washing machine and dryer.

Bathrooms – LPA Spaeth observed the bathrooms contained hand soap, paper towels, and a trash can.

Bedrooms – The bedrooms contained bed, linens, night stand, chair, chest of drawers, and a night lamp.

Office– LPA observed the staff office was locked.

Cont'd 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/04/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KELLY HOUSE INC
FACILITY NUMBER: 197609302
VISIT DATE: 10/04/2024
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Water Temperature - The water temperature was tested at 9:00 am and was 116.7 degrees F.

Garage - The garage was locked and contained workout equipment, cleaning solutions and additional PPE.

Hallway Cabinet- the hallway cabinet contained fresh linens and additional PPE supplies

Backyard –The backyard has a shaded area and the side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detector were tested at 10:43 am and are operational.

LPA reviewed client files at 9:20 am until 10:00 am. LPA reviewed the staff files at 10:00 am until 10:25 am.. LPA reviewed P&I at 10:30. LPA reviewed client medications at 10:35 until 10:40 am.

There are no deficiencies at this time.



Exit interview conducted, and a copy of the signed report was given to caregiver
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2024
LIC809 (FAS) - (06/04)
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