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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609302
Report Date: 04/14/2023
Date Signed: 04/14/2023 11:19:24 AM

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
03/21/2023 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20230321094118
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:
04/14/2023
UNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Rasheed Adetola OrenowoTIME COMPLETED:
11:30 AM
ALLEGATION(S):
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Staff restrained client in care
Staff did not provide proper medication assistance to client in care
INVESTIGATION FINDINGS:
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On 4/14/2023, Licensing Program Analyst (LPA) Spaeth arrived at the facility to conduct an unannounced complaint visit. Upon arrival, LPA was greeted by the facility manager. LPA conducted an entrance interview and explained the purpose of the visit. It was alleged that staff restrained client in care and staff did not provide proper medication assistance to client in care.

Staff restrained client in care – LPA interviewed six caregivers on 3/27/2023, 4/10/2023, 4/14/2023 who all stated do not use physical restraints when assisting residents. Staff confirmed the facility policy is not to use physical restraints when dealing with an aggressive resident and have been instructed to use redirection techniques. The six caregivers also stated never witnessed another caregiver restraining a resident or restrain a resident in a chair. LPA also interviewed the Administrator who stated has made it clear to caregivers that physical restraints are not to be used when dealing with aggressive residents. The caregivers and Administrator confirmed a resident has not reported physical restraint had occurred by a facility caregiver.




Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2023
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-20230321094118
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: 04/14/2023
NARRATIVE
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Staff did not provide proper medication assistance to client in care - LPA interviewed six caregivers on 3/27/2023, 4/10/2023 and 4/14/2023. LPA also interviewed the Administrator on 3/27/2023. The caregivers and Administrator stated staff applied cream to R1’s skin. The caregivers confirmed the resident was never asked to apply cream on own. The Administrator stated R1’s family member recommended an over-the- counter cream but R1’s dermatologist prescribed prescription creams for R1. The caregivers & Administrator also stated the prescribed creams were used and the staff stopped applying the over the counter cream when the dermatologist prescribed specific creams. Administrator confirmed resident was taken to a dermatologist on 2/06/2023 and 3/09/2023. Administrator and caregivers confirmed the resident had not stated was in pain due to skin issues. LPA also received copies of the dermatologist visits which indicates a specific cream was prescribed. The facility medication Administration records for 2/2023 and 3/2023 indicates the caregivers were applying the prescribed creams. Also the six caregivers and Administrator stated R1’s skin rash did not turn purple and dark.

Therefore, the allegations, staff restrained client in care and staff did not provide proper medication assistance to client in care is unsubstantiated. Exit interview conducted and a copy of the report was given to caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2