331880823-10-18-2024-18-AS-SJEN-DA6PER-20241018111534

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 331880823
Report Date: 10/18/2024
Date Signed: 10/18/2024 11:16:02 AM

Document Has Been Signed on 10/18/2024 11:16 AM - 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:	10/18/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Kelly Hentzen, administrator		TIME COMPLETED:	11:30 AM

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Licensing Program Analysts (LPA) Seo Jeon and Ferrer Sabarias conducted an unannounced annual required visit. Upon entry, LPA was greeted by Rosa Quintana, caregiver, and informed them of the purpose of the visit. At the time of the visit, there were (2) staff members and (6) residents present.

Facility Overview: The facility is a one-story home with (5) bedrooms and (3) bathrooms, including an attached garage. There are no pools or firearms on the premises.

Infection Control: LPA observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. The outdoor area was free of hazards. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked and inaccessible to residents. Fire extinguisher next to facility kitchen had current inspection tag. Both the smoke detector and carbon monoxide detector were operational, and the hot water temperature was 106.6°F.

Food Service: The facility’s kitchen was clean and equipped to prepare food. The facility maintained the required two-day supply of perishable foods and a seven-day supply of non-perishable foods.

Continued on LIC809-C....

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

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: 10/18/2024

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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate.

Record Review and Resident/Staff Files: LPA reviewed files for three staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Six resident files were reviewed and contained all required documentation.

Health-Related Services/Incidental Medical Services: All resident medications were securely locked. LPA reviewed medications for three residents, confirming that all medications were listed on the Medication Administration Record (MAR) and accounted for.

Disaster Preparedness: LPA reviewed the facility’s emergency and disaster plan, including documentation of the last quarterly fire drill conducted on 8-30-2024, which met department requirements. All facility exits were clear of obstructions.

No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed and provided to Kelly Hentzen, administrator.

SUPERVISOR'S NAME: Rikesha Stamps	TELEPHONE: (951) 212-0616
LICENSING EVALUATOR NAME: Seo Jeon	TELEPHONE: 951-248-0309
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024

LIC809 (FAS) - (06/04)

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