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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 10/19/2022
Date Signed: 10/19/2022 01:51:42 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
09/26/2022 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20220926084836
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:
10/19/2022
UNANNOUNCEDTIME BEGAN:
09:09 AM
MET WITH:Arnicia Johnson - House managerTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Resident was not accorded privacy by facility staff.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced subsequent complaint visit at this facility to investigate the above allegation. LPA met with house manager Arnica Johnson who called the administrator Tasha Kanaley and informed them of the purpose of the visit. She designated Ms. Johnson to sign the report.

LPA conducted physical plant tour at 9:22 AM, requested facility documents relevant to the investigation at 9:45 AM and interviewed additional staff and North LA Regional Center staff.

It was alleged that Staff #1 (S1) watched Resident #1 (R1) while changing inside the bathroom. LPA's interview with four (4) direct care staff on 10/04/22 between 10:00 AM to 1:00 PM revealed that R1 is only assigned female direct staff (1:1 staff) and no male staff is allowed to enter R1's room. Further, R1's bathroom is located inside R1's bedroom and it is exclusively for R1's use only. LPA's observation today at 9:35 AM and on 10/04/22 at 9:43 AM during physical plant tour confirmed that R1's bathroom is located inside R1's bedroom.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
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-20220926084836
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: 10/19/2022
NARRATIVE
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(continued from LIC 9099)

LPA's interview with S1 today at around 10:22 AM revealed that S1 was never assigned to R1 and denied entering R1's room as S1 was not allowed to. S1 also denied touching R1 at anytime. LPA's interview with three (3) residents on 10/04/22 between 10:00 AM to 1:00 PM revealed that no resident witnessed R1 or any resident being touched by any staff. LPA's record review and interview with four (4) direct care staff and two (2) additional staff on 10/04/22 between 10:00 AM to 1:00 PM also revealed that all residents have their own one to one staff at any given time and always have five (5) staff minimum during day time. LPA's interview with R1 on 10/04/22 at around 10:45 AM revealed that R1 was never touched by any staff at anytime and denied being watched by any staff while changing at the bathroom.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2