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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 331880823
Report Date: 10/27/2023
Date Signed: 12/04/2023 02:58:01 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 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
10/07/2021 and conducted by Evaluator Jesse Gardner
PUBLIC
COMPLAINT CONTROL NUMBER: 18-AS-20211007155211
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:
10/27/2023
UNANNOUNCEDTIME BEGAN:
10:28 AM
MET WITH:Caregiver Amelia RamirezTIME COMPLETED:
11:40 AM
ALLEGATION(S):
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Resident was financially abused while in care
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Jesse Gardner conducted an unannounced visit to investigate the above allegation. LPA met with Caregiver Amelia Ramirez. The investigation included interviews with staff, a review of facility documentation, and an inspection of the facility. The residents related to this investigation passed away prior to the concerns reported to the Department, therefore, LPA was unable to interview residents.

Allegation #1 stated that a resident was being financially abused. Information was reported that Resident 1 (R1) had paid for landscaping and a freezer for the facility. Licensee denied soliciting funds from R1.

Continued on LIC9099C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2023
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 18-AS-20211007155211
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 #2
FACILITY NUMBER: 331880823
VISIT DATE: 10/27/2023
NARRATIVE
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Licensee stated prior to R1 becoming a resident, R1 donated money toward a section of pavers in the backyard; however, LPA was not able to confirm this information. R2 also provided a plaque to be placed in the garden in honor of R2’s spouse who was a former resident at the facility; however, LPA was not able to confirm this information. The Licensee stated the freezer was not purchased by R1. Licensee provided a receipt to show proof of purchase which revealed the credit card used for the freezer purchase belonged to the Licensee.

Additional information provided by another witness provided conflicting information, therefore this allegation could not be corroborated.

Based on staff interview and record review, the allegation that resident was financially abused, is Unsubstantiated. A finding of UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violation did or did not occur.

An exit interview was conducted where a copy of this report was reviewed with and provided.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Jesse Gardner
LICENSING EVALUATOR SIGNATURE:

DATE: 10/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023
LIC9099 (FAS) - (06/04)
Page: 2 of 2