197609302-6-28-2022-31-AS-NGID-CGFSP2-20220718140223

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 06/28/2022
Date Signed: 06/28/2022 01:31:24 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 Joscelyn Martinez

PUBLIC

COMPLAINT CONTROL NUMBER: 31-AS-20220124170445

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:	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 caused injury to resident.
Staff does not take resident outside of the home.

INVESTIGATION FINDINGS:

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On 06/28/22 at 1:00 p.m Licensing Program Analysts (LPAs) Joscelyn Martinez and Wendell Smith arrived at the facility mentioned above to conduct a subsequent complaint visit and to deliver a revised 9099 issued on with additional details.

Allegation: Staff caused injury to resident.

It was reported that Resident #1 (R1) was verbally reprimanded and put on the floor with staff chocking R1 from behind for spilling strawberry lemonade on the carpet. Based on interviews, it was indicated that prior days staff had been asking R1 to remove a drink in the room, and when R1 spilled the drink on the floor R1 got angry. The individuals who witnessed the incident witnessed S1 perform a crisis prevention institute (CPI) hold on R1 where S1 put R1’s hands by their sides. It was indicated that R1 was attempting to hit S1 with a chair, and spit in S1’s face.

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-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: 06/28/2022

NARRATIVE

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The individuals who witnessed the incident they did not witness staff causing injury to the resident. Based on interviews one (1) out of three (3) residents indicated they have never seen injure a resident. Interviews with five (5) out of five (5) staff members indicated they have never seen a staff member injure a resident. Based on interviews with six(6) out of eight (8) individuals it was indicated that staff have not caused injury to residents in care. Therefore, due to a lack of supporting evidence, this allegation is deemed unsubstantiated.

Allegation: Staff encouraged resident to self-harm.

It was also reported that R1 threatened to drown themselves in the bathtub, and Staff #1 (S1) told R1 to go ahead and that S1 would not stop R1. Based on the observations of the individuals that witnessed the incident it was indicated that S1 did not encourage R1 to harm themselves. 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, due to a lack of supporting evidence, this allegation is deemed unsubstantiated.

Exit interview conducted and report delivered.

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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