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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 01/26/2023
Date Signed: 01/26/2023 12:20:21 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
01/24/2023 and conducted by Evaluator Nicholas Reed
COMPLAINT CONTROL NUMBER: 31-AS-20230124150514
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:
01/26/2023
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Adetola OrenowoTIME COMPLETED:
12:35 PM
ALLEGATION(S):
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Staff did not treat resident with dignity and respect
INVESTIGATION FINDINGS:
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At approximately 10:00 a.m. Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced complaint visit. LPA met with staff and disclosed the reason for the visit. LPA and staff toured the facility inside and out. No immediate health or safety concerns were observed.

LPA interviewed clients at 10:15 a.m., staff at 10:46 a.m., and the Administrator at 11:25 a.m. The Administrator stated that staff could sign today’s licensing report in her absence. LPA conducted a record review at 11:50 a.m.

Regarding the allegation above, it was alleged Staff #1 (S1) gave Client #1 (C1) a dirty look and gossiped about C1. From interviews, C1 stated the incident took place approximately two weeks ago and has not happened again since then. C1 did not provide additional details or explanations about the incident. S1 stated they did not gossip about or give a dirty look to C1. S1 and the Administrator noted C1 was angered after S1 denied C1’s romantic advances. C1 cussed at S1, and S1 walked away.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
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-20230124150514
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: 01/26/2023
NARRATIVE
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Other clients reported no issues with staff and felt they were treated with dignity and respect by staff. Staff reported no persisting issues with C1. Staff denied hearing about or witnessing dirty looks or gossip. Based on interviews, although the allegation may have happened or is valid, there is insufficient evidence to prove the alleged violation did or did not occur. Therefore, the allegation is deemed UNSUBSTANTIATED at this time.

Exit interview conducted. Appeal rights discussed. Copy of report provided.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 01/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2