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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603485
Report Date: 09/08/2022
Date Signed: 09/08/2022 11:17:29 AM

Document Has Been Signed on 09/08/2022 11:17 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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:POWELL HOUSE, INC.FACILITY NUMBER:
197603485
ADMINISTRATOR:AMALIA SANDIOVALFACILITY TYPE:
735
ADDRESS:1212 E. PASTEUR DR.TELEPHONE:
(661) 729-2175
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
09/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:57 AM
MET WITH:Amalia Sandioval, AdministratorTIME COMPLETED:
11:30 AM
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Licensing Program Analyst (LPA) Shira Stamps met with administrator Amalia Sandioval for an unannounced one (1) year Required visit for this facility.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitizer was available.

LPA arrived at 9:57am and was greeted by caregiver. One (1) client was observed in the kitchen eating breakfast. The rest of the clients were observed to be in their room sleeping, watching TV and/or resting. Administrator arrived at 10:17am. LPA informed the Administrator of the purpose of the visit. Entrance interview conducted

A tour of the physical plant was conducted with Administrator at 10:20am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory.

Food Inspection
LPA conducted tour at the kitchen around 10:25am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp objects, medications, and chemicals being locked and inaccessible to clients in care.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/08/2022
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, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELL HOUSE, INC.
FACILITY NUMBER: 197603485
VISIT DATE: 09/08/2022
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Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:37am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 03/31/22. Staff and client files were observed to be locked and inaccessible to clients in care.

Laundry
At 10:30am, LPA observed one cabinet unlocked containing chemicals/hazardous items in the laundry room. The Administrator immediately locked the cabinet. The lock was some what hard to lock, and the lock may need to be replaced. At 11:10am LPA observed the the Administrator contact the repair personnel to repair the lock.

Physical environment
LPA toured the outside area of the facility at 10:31am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
At 10:36am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 110.1 degrees F.

Garage
LPA observed the garage to be attached to the facility and currently being used for an extra food storage.

Administrative: LPA collected the LIC.500 and client roster. Annual fee is current. LPA reviewed over maintaining records and files to be prepared for full inspections. LPA reviewed COVID training files and the infection control plan. An exit interview was conducted, citation issued, and a copy of this report and appeal rights were given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 09/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/08/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/08/2022 11:17 AM - It Cannot Be Edited


Created By: Shira Stamps On 09/08/2022 at 11:00 AM
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
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: POWELL HOUSE, INC.
FACILITY NUMBER: 197603485

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/08/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80087(g)
80087(g) Building and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

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 that the laundry room cabinet containing disinfectants and cleaning solutions was unlocked, which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/09/2022
Plan of Correction
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The Administrator stated she will replace the lock, and provide the receipt to the LPA by the Plan of correction due date.
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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 09/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/08/2022


LIC809 (FAS) - (06/04)
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