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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603485
Report Date: 01/11/2024
Date Signed: 01/11/2024 12:39:38 PM

Document Has Been Signed on 01/11/2024 12:39 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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:
01/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amalia SandovalTIME COMPLETED:
12:55 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with administrator Amalia Sandoval for an unannounced one (1) year Required visit for this facility.

Infection control: LPA reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations.

LPA arrived at 9:30 am and was greeted by Administrator. One (1) client was observed in the living room waiting on day program ride. One (1) client observed to be in their room resting. LPA informed the Administrator of the purpose of the visit. Entrance interview conducted.

A tour of the physical plant was conducted with Administrator at 10:15 am. 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 10:20 am observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects, medications, and chemicals being locked and inaccessible to clients in care.

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 10:30 am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 10/16/2023. Staff and client files were observed to be locked and inaccessible to clients in care.
Continued 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELL HOUSE, INC.
FACILITY NUMBER: 197603485
VISIT DATE: 01/11/2024
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Laundry: At 10:31 am LPA observed detergents and chemicals to be locked.

Physical environment: LPA toured the outside area of the facility at 10:35 am. LPA observed appropriate outdoor furniture, with an umbrella for shade. No bodies of water on the premises.

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

Bathrooms: At 10:36 am 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 116.2 degrees F.

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

Administrative: LPA collected the LIC.500, client roster and Insurance/Bond. Annual fee is current.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 10:50 am.



Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:20 am.

Medications: At 11:35 am LPA and Administrator reviewed medication and medication records for proper documentation.

Staff Interviews: At 11:45 pm LPA interviewed staff.

Client Interviews: At 12:00 pm LPA interviewed clients present in the home.

An exit interview was conducted. No deficiencies noted at this time, no citations issued. A copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/11/2024
LIC809 (FAS) - (06/04)
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