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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 415601174
Report Date: 04/10/2025
Date Signed: 04/11/2025 10:51:13 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/06/2025 and conducted by Evaluator Audrey Jeung
PUBLIC
COMPLAINT CONTROL NUMBER: 14-AS-20250106152958
FACILITY NAME:KELLY'S HOMEFACILITY NUMBER:
415601174
ADMINISTRATOR:ANCHETA, KELLYFACILITY TYPE:
735
ADDRESS:1997 SHOREVIEW AVENUETELEPHONE:
(650) 888-7618
CITY:SAN MATEOSTATE: CAZIP CODE:
94401
CAPACITY:6CENSUS: 2DATE:
04/10/2025
UNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Enrico ReyesTIME COMPLETED:
09:30 AM
ALLEGATION(S):
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9
Facility staff are not answering communications from resident's relative(s)
INVESTIGATION FINDINGS:
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Based on review of email communications, voice mails, and interviews with staff, this allegation is determined to be unsubstantiated. Although the allegation may have occurred or is valid, there is not enough evidence to prove the alleged violation did or did not occur.

Complainant alleges that facility staff was contacted on 1/1/25. However, staff-- including licensee and administrator--denied that complainant contacted them on 1/1/25. On 12/31/24, however, after visiting facility, complainant contacted administrator by leaving voice mail; there was no request for a return call. Several hours later, complainant sent text message to administrator, and requested a call back. Instead of calling complainant, administrator emailed client's court appointed care manager, court appointed conservator and GGRC social worker on 1/2/25 to report that complainant was annoyed and verbally aggressive to staff because she was not informed that client had a visitor at the same time as complainant's visit on 12/31/24. In addition, complainant stated that client's clothing was ripped, and requested that he always be dressed appropriately in clothing in good condition. Continued on page TWO.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
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 14-AS-20250106152958
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BRUNO RO, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME: KELLY'S HOME
FACILITY NUMBER: 415601174
VISIT DATE: 04/10/2025
NARRATIVE
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Continued from page ONE.

According to the court appointed care manager who visited client when complainant visited on 12/31/24, client was dressed appropriately and clothing was not ripped.

This is one of many investigations conducted by this agency as a result of allegations filed by complainant when facility was licensed as a children's residential home.
SUPERVISORS NAME: April Cowan
LICENSING EVALUATOR NAME: Audrey Jeung
LICENSING EVALUATOR SIGNATURE:

DATE: 04/10/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 2