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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 01/19/2023
Date Signed: 01/19/2023 01:45:43 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
01/11/2023 and conducted by Evaluator Michael Cava
COMPLAINT CONTROL NUMBER: 31-AS-20230111091733
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:
01/19/2023
UNANNOUNCEDTIME BEGAN:
09:24 AM
MET WITH:Tasha Kanaley, Armando RenteriaTIME COMPLETED:
02:00 PM
ALLEGATION(S):
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Staff deny clients right to refuse medications
Staff do not allow client to recieve medical care of their own choosing
Staff yells at client in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Michael Cava conducted a complaint visit to the facility to investigate the above allegations. LPA met with the administrator, Tasha Kanaly, and her staff, Armando Renteria, and advised them of the complaint. The day's investigation consisted of interviews with staff and residents, record review and a physical plant inspection. Between 9:40am-12:00pm, LPA conducted interviews and a physical plant inpsection. Approximately 12:00pm-1:00pm, record reviews were made.

Staff deny clients rights to refuse medications:
In regards to the allegation, it was reported that staff is forcing to make Resident 1 (R1) take medication against their will. Interviews with staff and residents do not corroborate with the allegation. LPA conducted a record review of R1's Medication Administration Record (MAR) and didn't observe any discrepancy. LPA did observe refusal on R1's MAR, indicating there was no force. When the administrator and staff was asked why the refusal, they both indicated because R1 didn't want to take the medicine as a pill form. Both
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
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-20230111091733
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: 01/19/2023
NARRATIVE
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administrator and staff stated R1's doctor is aware of this behavior. It was also explained to R1 the importance to take their medication as prescribed in compliance with the house rules. Based on the information obtained, there was insufficient evidence to prove that staff are denying resident to refuse to take their medicine. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff do not allow client to receive medical care of their own choosing:
In regards to the allegation, it was reported that the administrator is refusing to allow R1 to change doctors so that R1 can be re-evaluated and prescribed a different medication. According to the administrator and staff, R1 would get upset if they do not get the prescription they want. Since admission, R1 has had a history of doing so. R1's doctor was made aware of this behavior, and both the doctor and the administrator has advised R1 that their prescription is ordered based on their assessment and examination during their doctor visits. Administrator stated R1 was never denied to change their medical provider. R1 is alert and capable of making their own change. Staff has offered to assist, but R1 never follows through. Interviews with residents do not corroborate the allegation. Residents do have the right to choose, depending on their health care plan. Based on the information obtained, there was insufficient evidence to prove that staff do not allow clients to receive medical care of their own choosing. Therefore, the allegation is deemed Unsubstantiated at this time.

Staff yells at client in care:
In regards to the allegation, it was reported that the administrator yells at R1. Interviews with clients do not corroborate the allegation. Interview with the administrator reveal that it is R1 who is aggressive, towards staff. Administrator stated R1 is especially abusive towards female staff. A review of R1's Individual Program Plan (IPP) indicate that R1 has had a Cease and Desist Inappropriate and Threatening comment letter filed against them from Regional Center (RC) as a result of behavior and statements made towards RC staff. R1 is to no longer have direct contact with CSC or RC staff because of their behavior. Furthermore, on 01/11/23, an incident report was submitted to CCL indicating that R1 had verbal threats towards the administrator. Copy of screen shots of R1's threats via text messages obtained. Based on the information obtained, there was insufficient evidence to to prove that staff yells at R1. Therefore, the allegation is deemed Unsubstantiated at this time.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 01/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/19/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2