331880680-10-12-2021-18-AS-MVAO-CTVUTU-20230719155230

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 331880680
Report Date: 10/12/2021
Date Signed: 10/12/2021 12:39:36 PM

Unfounded

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/07/2021 and conducted by Evaluator Jesse Gardner

COMPLAINT CONTROL NUMBER: 18-AS-20211007153731

FACILITY NAME:	KELLY'S PLACE		FACILITY NUMBER:	331880680
ADMINISTRATOR:	HENTZEN, KELLY J		FACILITY TYPE:	740
ADDRESS:	119 AZURRO DR		TELEPHONE:	(818) 314-4377
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	6	CENSUS: 6	DATE:	10/12/2021
		UNANNOUNCED	TIME BEGAN:	11:10 AM
MET WITH:	Malissa Wood, Caregiver		TIME COMPLETED:	12:30 PM

ALLEGATION(S):

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Resident was financially abused while in care.

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Jesse Gardner arrived at the facility unannounced to conduct an investigation into the above allegation. LPA Gardner met with Caregiver Malissa Wood. LPA Gardner explained the purpose of the visit, and was granted access.

After a confidential interview, as well as interviews with staff, it was determined that the above allegation was in reference to a client who lived at another facility. The allegation was deemed to be UNFOUNDED. An UNFOUNDED is a meaning that the allegations were false, could not have happened and/or is without a reasonable basis.

A copy of this report was reviewed with and given to Licensee Kelly Hentzen.

Unfounded

Estimated Days of Completion:

SUPERVISOR'S NAME: Reyna Lacey	TELEPHONE: (951) 248-0341
LICENSING EVALUATOR NAME: Jesse Gardner	TELEPHONE: (951) 205-2683
LICENSING EVALUATOR SIGNATURE:	DATE: 10/12/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/12/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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