331880823-10-19-2023-18-AS-JARA-CWS4U6-20231019192412

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880823
Report Date: 10/19/2023
Date Signed: 10/19/2023 07:24:17 PM

Document Has Been Signed on 10/19/2023 07:24 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

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

FACILITY NAME:	KELLY'S PLACE #2		FACILITY NUMBER:	331880823
ADMINISTRATOR:	HENTZEN, KELLY J		FACILITY TYPE:	740
ADDRESS:	117 AZZURO DRIVE		TELEPHONE:	(442) 334-7679
CITY:	PALM DESERT	STATE: CA	ZIP CODE:	92211
CAPACITY:	6	CENSUS: 6	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	05:30 PM
MET WITH:	Licensee, Kelly Hentzen		TIME COMPLETED:	07:35 PM

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On 10/19/2023, Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced annual required visit. LPA was granted entry and met with Licensee, Kelly Hentzen, who was informed of the purpose of the visit. At the time of the visit there was (2) staff and (6) residents present.

The facility is a one story home with (6) bedrooms and (3) bathrooms. The residents served are elderly ages 60 and above. LPA conducted a tour of the interior and exterior and observed the following:

Infection Control: The LPA observed hand washing stations with hand hygiene supplies and hand washing signs. LPA observed PPE equipment and cleaning supplies to do regular cleaning of the facility. The facility has a plan to train and follow infection control guidelines.

Physical Plant: Physical plant was observed to be clean and in good repair. The indoor and outdoor areas were observed to be free of hazards. Laundry equipment was observed to be in good working condition. The sharp and dangerous objects were observed to be locked and inaccessible to residents. The smoke detector and carbon monoxide was operational, and the hot water temperature was recorded at 105F.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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

LIC809 (FAS) - (06/04)

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: KELLY'S PLACE #2	FACILITY NUMBER: 331880823
	VISIT DATE: 10/19/2023

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Food Service: LPA observed facility kitchen had the ability to prepare food in clean environment and possessed equipment in good working condition. LPA observed the facility met the required 2-day supply of perishable and 7-day supply of non-perishable foods.

Record Review and Resident/Staff Files: LPA reviewed (2) staff files and training. All staff have criminal clearance and updated training along with CPR/First Aid Certification. The listed administrator showed the LPA proof of a pending administrator's certificate. Two (2) resident files were reviewed, and possessed all required paperwork.

Health Related Services/ Incidental Medical Services: All client medication was locked. Resident medications were reviewed, all of which were accounted for.

Disaster preparedness: LPA reviewed the facility's emergency and disaster plan. The last fire drill was conducted 9/6/2023. LPA observed emergency exits and emergency supplies.

No deficiencies were cited at the time of the visit. An exit interview was conducted where a copy of this report was provided to Licensee, Kelly Hentzen.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Janira Arreola	TELEPHONE: 951-248-2222
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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