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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880680
Report Date: 04/15/2024
Date Signed: 04/15/2024 02:28:31 PM

Document Has Been Signed on 04/15/2024 02:28 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 PLACEFACILITY NUMBER:
331880680
ADMINISTRATOR/
DIRECTOR:		HENTZEN, KELLY JFACILITY TYPE:
740
ADDRESS:119 AZURRO DRTELEPHONE:
(818) 314-4377
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY: 6CENSUS: 6DATE:
04/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Kelly Hentzen - Licensee/AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of conducting the annual inspection. LPA Colvin met with Administrator/Licensee Kelly Hentzen and informed her of the purpose of today's inspection. Below is a summary of what was observed:

Infection Control: LPA Colvin observed that the facility has an updated Infection Control Plan on file and is demonstrating best practices in the facility to maintain a healthy environment for staff and residents. Such measures include soap and paper towels at hand washing stations, posted hand washing guides, and tight-fitting lids on trash cans.

Physical Plant: LPA Colvin toured the facility and observed that there a sufficient bedrooms and bathrooms for both staff and residents. LPA Colvin observed the required furniture and linen to be present and in good condition in resident bedrooms. LPA Colvin measured the hot water in the bathroom faucets to be 122 degrees. Deficiency cited. Administrator/Licensee Kelly Hentzen informed LPA Colvin that she has been struggling with the hot water measuring too hot in the bathrooms but then not hot enough in the kitchen. Administrator/Licensee Kelly Hentzen stated that she plans on replacing the hot water heater, as other attempts to repair it have failed. The facility's carbon monoxide alarm and smoke detectors were recently tested for an updated fire clearance on 4/8/24 and were operational. Knives and other sharp objects are kept locked in a cabinet in the kitchen. Chemicals are locked in the laundry room. LPA Colvin observed sufficient supply of perishable and non-perishable food and utensils and dishes for the residents in care.

Operational Requirements: LPA Colvin observed the facility to be operating within their licensed capacity of 6 non-ambulatory residents, one of which may be bedridden. Facility has a hospice waiver for 4 residents.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/15/2024
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
FACILITY NUMBER: 331880680
VISIT DATE: 04/15/2024
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Staffing & Staff Records: LPA Colvin confirmed that there are sufficient staff present to meet the needs of residents. LPA Colvin additionally confirmed that the facility has an Administrator with a current Administrator Certificate. LPA Colvin reviewed staff records and confirmed current CPR/First Aid Certification as well as training relevant to the facility and residents' needs.

Resident Records: LPA Colvin reviewed the files for all 6 current residents to confirm that they have the required information present in their files, including Physician's Report, Admissions Agreement, and current Needs & Services Plan.

Incidental Medical Services: LPA Colvin observed that resident medication is locked in a cabinet in the laundry room and is inaccessible to residents. LPA Colvin confirmed that the facility is not retaining any residents with prohibited health conditions.



Planned Activities: LPA Colvin observed residents participating in various activities, such as puzzles, watching television, listening to music, and exercising.

Emergency Disaster Preparedness: LPA Colvin confirmed that the facility has an Emergency Disaster Plan on file and are conducting quarterly disaster drills.

An exit interview was conducted with Administrator/Licensee Kelly Hentzen and a copy of this report, LIC809D, LIC9098 Proof of Corrections, and appeal rights were provided.
SUPERVISORS NAME: Tricia Danielson
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 04/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 04/15/2024 02:28 PM - It Cannot Be Edited


Created By: Crystal Colvin On 04/15/2024 at 01:59 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S PLACE
FACILITY NUMBER: 331880680

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/15/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation: (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in 1 resident bathroom sink, which poses an immediate safety risk to persons in care. LPA Colvin measured the hot water in one shared resident bathroom and observed it to be measuring at 122 degrees.
POC Due Date: 04/16/2024
Plan of Correction
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Licensee states that they are getting a quote to replace the hot water heater, as the tempurature is measuring too hot in the bathrooms, but not hot enough in the kitchen, so adjusting the hot water tempurature will not resolve the issue completely. Licensee to provide LPA Colvin with a date of when the hot water heater will be installed, and provide this information by the Plan of Correction date of 4/16/24.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Tricia Danielson
LICENSING EVALUATOR NAME:Crystal Colvin
LICENSING EVALUATOR SIGNATURE:
DATE: 04/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/15/2024


LIC809 (FAS) - (06/04)
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