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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 331880823
Report Date: 10/13/2022
Date Signed: 10/13/2022 11:39:46 AM

Document Has Been Signed on 10/13/2022 11:39 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
CCLD Regional Office, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
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
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Rosa Quintana - CaregiverTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Crystal Colvin arrived at the facility unannounced for the purpose of completing the facility's Annual Inspection. LPA Colvin met with caregiver Rosa Quintana and advised of the purpose of the visit, and that the Annual Inspection will be limited to Infection Control only. LPA Colvin additionally spoke with Administrator Kelly Hentzen via telephone, and went over the questions/areas for the Infection Control annual. Below is a summary of what was observed:

Infection Control: LPA Colvin went over COVID-19 best practices for infection control and prevention with Administrator Kelly Hentzen, who LPA Colvin found to be successfully incorporating the several aspects of COVID-19 best practices. Residents have hand sanitizer available to them, and the bathrooms were stocked with hand soap and paper towel. While touring the facility, LPA Colvin observed postings throughout the facility for cough etiquette, social distancing, and infection control. LPA Colvin requested to view the facility's PPE supplies (gloves, masks, and sanitizer, and isolation gowns), which was located in a locked the laundry room, as well as at the front door and accessible to staff and visitors. LPA Colvin observed the facility to have at least a 30-day supply of PPE. LPA Colvin went over the various recommended training for facility staff with Administrator Kelly Hentzen in relation to COVID-19 and confirmed that staff have been trained on various aspects of infection control, recognition of symptoms of COVID-19, and donning/doffing PPE.

LPA Colvin inquired as to if staff have been fit tested for N95 masks, and Administrator Kelly Hentzen informed LPA Colvin that at this time staff have only been trained on donning/doffing PPE. LPA Colvin will be issuing a TA Advisory Note during today's inspection for staff not being fit tested for N95 masks. LPA Colvin will not be issuing a deficiency for this item due to the facility not currently having any COVID-19 positive residents, and N95 masks only needing to be worn when a resident is COVID-19 positive or under observation while awaiting test results. LPA Colvin will be providing Administrator with the information for Provider Information Notice (PIN) PIN-21-10-ASC which contains resources for getting staff fit tested for N95 masks.
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.

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
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
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An exit interview was conducted with Administrator Kelly Hentzen and a copy of this report and LIC9102 TA Advisory Notes was provided to staff Rosa Quintana, who additionally signed for the report as Administrator was not present.
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
LIC809 (FAS) - (06/04)
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