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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609302
Report Date: 04/05/2022
Date Signed: 04/05/2022 01:21:36 PM

Document Has Been Signed on 04/05/2022 01:21 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: 5DATE:
04/05/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:25 PM
MET WITH: Tekoa Huey, Co-AdministratorTIME COMPLETED:
01:35 PM
NARRATIVE
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At 12:25pm, Licensing Program Analyst (LPA) Shira Stamps conducted an unannounced case management visit to this facility in conjunction with complaint control number 31-AS-20220124170445. The purpose of this Case Management visit is to issue a citation for a deficiency observed during the course of the complaint investigation that is not directly related to the complaint allegation.

A review of the facilities medication log for R1 revealed that for the month of January and February the facility did not report to Community Care Licensing the resident’s refusal of medications thirty-two (32) out of thirty-three (33) days the resident refused their medications. During interviews, it was revealed that S1 used emergency intervention techniques for R1 by manually restraining the residents hands. A review of the facility program and plan of operation revealed that the facility did not provide a developed emergency intervention plan to the Department prior to the use of manual restraint.

Exit interview conducted, citation issued, and report and appeals rights 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
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
Document Has Been Signed on 04/05/2022 01:21 PM - It Cannot Be Edited


Created By: Shira Stamps On 04/05/2022 at 12:49 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KELLY HOUSE INC
FACILITY NUMBER: 197609302

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/05/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
04/12/2022
Section Cited
CCR
80061(b)

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80061(b) Upon the occurrence...reports shall be made to the licensing agency within the agency's next working day... written reports shall be submitted to the licensing agency within seven days...

This requirement was not met as evidence by:
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The Administrator stated staff training was completed in 2/2022, with a review of reporting medication refusals and how to document each occurance. The Administrator stated she will provide proof of training to LPA.
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Based on review of the facilities medication log and incident reports submitted to the Licensing agency, the Licensee did not report the unusual incident of medication refusal, which is a potential health and safety risk to the resident in care.
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Type B
04/12/2022
Section Cited
CCR85122(a)

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85122 (a) The... licensee shall be responsible to ensure an Emergency Intervention Plan is developed and approved by the Department prior to the use of manual restraint...

This requirement was not met as evidence by:
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The Administrator stated they will submit an emergency interviention plan to the LPA.
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Based on interviews and review of the plan of operation the Licensee did not ensure an emergency intervention plan was developed and approved by the Department prior to the use of manual restraint, which is a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 04/05/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/05/2022


LIC809 (FAS) - (06/04)
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