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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603485
Report Date: 05/13/2025
Date Signed: 05/13/2025 03:39:46 PM

Document Has Been Signed on 05/13/2025 03:39 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/
DIRECTOR:		AMALIA SANDIOVALFACILITY TYPE:
735
ADDRESS:1212 E. PASTEUR DR.TELEPHONE:
(661) 729-2175
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
05/13/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Amalia SandovalTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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At 09:30 am on 05/13/2025, Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced case management visit. LPA met with Administrator Amalia Sandoval and disclosed the reason for the visit.

Today’s case management visit is to follow up on a special incident reported to LPA Casillas on 05/12/25 for incident reported to another facility on 04/18/25. It was reported that the facility in which Client #1 (C1) resides in, that C1 only ate dinner one (1) time on the week of reporting. It was also reported that only a granola bar is being provided to C1 for lunch. The purpose of the visit is to obtain additional information regarding this incident.

LPA toured the facility, reviewed and collected pertinent documents, and interviewed Administrator, staff #1 (S1), and C1, from 09:45 am to 12:00 pm.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/13/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELL HOUSE, INC.
FACILITY NUMBER: 197603485
VISIT DATE: 05/13/2025
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On 04/18/25 it was reported that C1 had stated that they have not had dinner but once, the week of the report. C1 stated that the facility only provided “ceviche” and that fish had been cooked three (3) times that week. It is also reported that C1 is only being provided granola bars for lunch while attending day program. LPA interviewed Administrator who states that the facility provides three (3) nutritious meals a day with snacks in between. C1 is provided a full lunch for day program, however, according to Administrator and S1, back in April C1 was leaving their meals behind because C1 stated that they wanted to lose weight, this was something that C1 initiated. Per Administrator and staff this is an ongoing situation for C1 in which they refuse to eat the food provided because C1 continuously wants to lose weight but C1 also likes to eat out, as opposed to eating the meals provided. Administrator states that this is part of C1’s ongoing behavior. S1 stated that C1 sometimes states that they are allergic to the meals provided, primarily seafood, however there is no documentation to reflect that there is an actual allergy. S1 stated that all the clients are included every Monday, in the decision making for meals to be put on the menu and they all have their requests respected. LPA interviewed C1 who stated that they never said that they didn’t eat or wasn’t fed. C1 stated that they chose to only eat a granola bar because C1 was trying to lose weight, but that the facility always provides meals. C1 also stated that they participate every Monday in the decision making for the meals of the week and when C1 does not like something the staff always offer an alternative. LPA asked C1 if C1 was taking their lunch to program, C1 stated that they are now since the staff conversed with C1 on the importance of eating.

Since this incident was unknown to the facility, they were not able to report it. However, the staff has taken the appropriate actions to ensure that C1’s lunch is either taken by C1 or given to the driver for the day program when staff observe the food being left behind. Administrator provided LPA with food menus for the last 3 months and food menu for the following week. LPA checked food inventory and there is sufficient amount of two-day perishable and seven-day nonperishable foods. LPA was also able to observe that the menu for next week is posted and the food on the menu is available. Furthermore, the staff has taken appropriate action and made a request for a referral to the allergist to find out if C1 is allergic to any food items so they can be excluded from C1’s meals. Therefore, there are no deficiencies cited at this time.

Exit interview conducted. Copy of report provided to Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/13/2025
LIC809 (FAS) - (06/04)
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