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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 07/26/2022
Date Signed: 07/26/2022 01:36:55 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
07/19/2022 and conducted by Evaluator Angela Panushkina
COMPLAINT CONTROL NUMBER: 31-AS-20220719121914
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:
07/26/2022
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adetola Orenowo, Staff member TIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Facility is not providing resident with proper care and supervision.
INVESTIGATION FINDINGS:
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At 10:00am Licensing Program Analysts (LPAs) Angela Panushkina and Patrick Shanahan conducted an initial complaint visit to this facility to investigate the allegation mentioned above. LPA was greeted by a staff member who granted access to home. Administrator was contacted on the phone and the purpose of this visit was explained.
LPAs conducted interviews (between 10:50am – 1:00pm) with the Administrator, 5 out of 5 staff, 2 out of 4 residents and reviewed facility records. LPA also obtained copies of pertinent documents relevant to the investigation.

Allegation: Facility is not providing resident with proper care and supervision.
Interview with C1 indicated that the facility Administrator will cut off the internet access and won't allow C1 to complete the meeting with the Regional Center (RC). C1 informed LPAs that the zoom meeting was for about 15 to 20 minutes, instead of the full 90 minutes and it doesn’t give enough time for C1 to discuss (RC) Continue on LIC809-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20220719121914
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: 07/26/2022
NARRATIVE
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services. Moreover, interview with C1 revealed that the meeting on 07/15/22 was cut short due to C1’s threats made towards RC, facility staff members and themselves.

Interview with the Administrator revealed that during the RC meeting on 07/15/22, C1 began yelling, cursing, and threatening to harm themselves and others which led to an immediate cancelation of the meeting. Interviews with two (2) out of five (5) staff members (that were present at the office during the meeting- S1 and S2) revealed that RC was waiting for C1 to finish talking, so they could address the concerns and answer all of the questions brought up to their attention. S1 and S2 informed LPAs that for about three (3) times during the meeting, they had to redirect C1 to talk about Individual Personalized Plan (IPP). Five (5) staff members denied restraining C1 and confirmed RC canceling the meeting.

Based on information obtained through interviews and record reviews this allegation is deemed Unsubstantiated at this time.




Exit interview conducted and copy of the report given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2