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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880680
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:59:07 PM

Document Has Been Signed on 12/13/2023 02:59 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 AC/SC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:KELLY'S PLACEFACILITY NUMBER:
331880680
ADMINISTRATOR:HENTZEN, KELLY JFACILITY TYPE:
740
ADDRESS:119 AZURRO DRTELEPHONE:
(818) 314-4377
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 5DATE:
12/13/2023
TYPE OF VISIT:CollateralUNANNOUNCEDTIME BEGAN:
01:55 PM
MET WITH:Licensee, Kelly J Hentzen TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Kathleen Banrasavong arrived unannounced to the facility to conduct a collateral visit for a complaint from Desert Cottage II, on the health, safety, and welfare of residents in care. RIV RO, Community Care Licensing received a complaint on 12/06/2023 in regards to Resident 1 (R1). LPA met with the Licensee, Kelly J Hentzen to inform her of the purpose of the visit and was granted entry.

LPA toured the facility and observed all facility utilities to be on and operating without issues. Food supply is sufficient. There is no immediate concern for residents in care. LPA conducted an interview with R1 and request pertinent documents for the collateral visit.

No deficiencies are being cited and no civil penalties per California Health & Safety Code and Code of Regulations, Title 22, Division 6. An exit interview was conducted with Licensee, Kelly J Hentzen and a copy of this report is left with the her as evidence by her signature.

SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Kathleen Banrasavong
LICENSING EVALUATOR SIGNATURE: DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/13/2023
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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