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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880823
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:40:13 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/06/2022 and conducted by Evaluator Crystal Colvin
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20221006150834
FACILITY NAME:KELLY'S PLACE #2FACILITY NUMBER:
331880823
ADMINISTRATOR:HENTZEN, KELLY JFACILITY TYPE:
740
ADDRESS:117 AZZURO DRIVETELEPHONE:
(442) 334-7679
CITY:PALM DESERTSTATE: CAZIP CODE:
92211
CAPACITY:6CENSUS: 6DATE:
10/13/2022
UNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Rosa Quintana - CaregiverTIME COMPLETED:
11:15 AM
ALLEGATION(S):
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Staff did not prevent resident from eloping from the facility.
INVESTIGATION FINDINGS:
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On today's date, Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of initiating an investigation with the above allegation. LPAs Colvin met with caregiver Rosa Quintana. Below is a summary of the findings of the investigation:

Regarding allegation "Staff did not prevent resident from eloping from the facility.": LPA Colvin reviewed the resident's (R1) facility file, including Special Incident Report submitted by the facility on 10/3/22, and conducted interviews with staff. LPA Colvin confirmed that on 10/1/22 at approxiamtely 4:00am, R1 exited from the facility without staff's (S1) knowledge, as S1 had fallen asleep on the couch in the livingroom, sometime around 2pm or 3pm. According to interviews conducted, this was the first attempt R1 had made to exit the facility since R1 moved in August 2022. Licensee reports that R1's family stated that R1 did have a hisotry of leaving prior placement, though wandering behavior is not listed on R1's Physician's Report. Due to interviews and record review, the allegation "Staff did not prevent resident from eloping from the facility" is SUBSTANTIATED.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
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 3
Control Number 18-AS-20221006150834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: KELLY'S PLACE #2
FACILITY NUMBER: 331880823
VISIT DATE: 10/13/2022
NARRATIVE
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 A finding that the complaint is SUBSTANTIATED means that the allegation(s) is valid because the preponderance of the evidence standard has been met.

Due to observations made by LPA Colvin, the facility was cited and deficiencies noted on LIC 9099 D. An exit interview was conducted where this report and appeal rights were discussed. A copy this report, LIC 9099D, and appeal rights were provided to caregiver Rosa Quintana during the exit interview.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3
Control Number 18-AS-20221006150834
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: KELLY'S PLACE #2
FACILITY NUMBER: 331880823
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/13/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/14/2022
Section Cited
CCR
87468.2
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Additional Personal Rights of Residents in Privately Operated Facilities: (a) In addition to the rights listed...residents...shall have all of the following personal rights: (4) To care, supervision, and services that meet their individual needs and are delivered by staff ...to meet their needs. This was not met by:
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Licensee agrees to formulate plan for additional duties/tasks for NOC shaft to accomplish during their shift so that they are not spending large amounts of time sitting down, where they might fall asleep. Licensee to provide LPA Colvin with plan by Plan of Correction date of 10/14/22.
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The Licensee did not comply with the above regulation with at least one resident. LPA Colvin confirmed that on 10/1/22, R1 exited the facility without staff knowledge due to S1 having falled asleep. This was an immediate health and safety risk for R1.
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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.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 3