Aging and People with Disabilities
Safety, Oversight and Quality
Print Inspection: YI2X
Provider Information
12221 SE KELLY STREET
Portland, OR 97236
- Provider ID
- 50R454
- Administrator
- Maricel Asa
- Phone
- (503) 954-2561
- maricel@kellyvillercfpdx.com
Inspection Details
- Date
- 8/11/2025
- Event ID
- YI2X
- Inspection type(s)
- Complaint Investig.
- Deficiencies cited
- 3
Citation Details
C0010: Licensing Complaint Investigation
- Visit Number
- 1
- Visit Date
- 8/11/2025
- Corrected Date
- N/A
- Details
-
10 Tag info
Assisted Living and Residential Care Facilities must operate and provide services in compliance with all applicable State and local laws, regulations and codes. This report reflects the findings of the complaint investigation conducted 08/11/25. The facility was evaluated for compliance with Oregon Administrative Rule 411, Division 54 and if applicable, Oregon Administrative Rule 411, Division 57. The following deficiencies were identified:
Abbreviations possibly used in this document:
ADL:activities of daily living
CBG:capillary blood glucose or blood sugar
CG:caregiver
CS: Compliance Specialist
cm:centimeter
ED:Executive Director
F:Fahrenheit
HH:Home Health
HS:Hours of sleep
LPN:Licensed Practical Nurse
MT: Medication Technician or Med Tech
MAR:Medication Administration Record
MCC:Memory Care Community
OT:Occupational Therapist
PT: Physical Therapist
PRN:as needed
RCC:Resident Care Coordinator
RN:Registered Nurse
SP:Service plan
SPT:Service Planning Team
TAR:Treatment Administration Record
C0362: Acuity Based Staffing Tool - Abst Time
- Visit Number
- 1
- Visit Date
- 8/11/2025
- Corrected Date
- N/A
- Details
-
C0363: Acuity Based Staffing Tool - Updates & Plan
- Visit Number
- 1
- Visit Date
- 8/11/2025
- Corrected Date
- N/A
- Details
-