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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603907
Report Date: 10/31/2022
Date Signed: 10/31/2022 03:45:15 PM

Document Has Been Signed on 10/31/2022 03:45 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:POWELSON HOME IIFACILITY NUMBER:
197603907
ADMINISTRATOR:CHRISTIN SOLISFACILITY TYPE:
735
ADDRESS:16355 LONDELIUS ST.TELEPHONE:
(818) 891-2860
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Christian SolisTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced Required Annual visit and inspection of the facility mentioned above. LPA met with Staff (S1) who took LPA's temperature and signed in on visitor log. S1 granted access and designated Administrator, Christian Solis met us shortly after and explained the reason for the visit.

At approximately 2:15 p.m., with the assistance of the administrator, LPA took a tour of the physical plant.
Required postings were observed in the entry area. The smoke alarms are battery operated and hard wired. The carbon monoxide detector functions properly. The fire extinguisher is located in the kitchen. The charge date is 5/11/2022.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the locked staff room.

Bedrooms: There are a total of four (4) bedrooms in the home three (3) are designated for clients and one (1) is for staff.. One (1) out of the (3) client bedrooms is shared by two clients. Each of the resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are a total of two (2) bathrooms in the home which are all designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114.9 degrees Fahrenheit. No toxins or hazardous items observed as cleaning supplies is not kept underneath the kitchen sink.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELSON HOME II
FACILITY NUMBER: 197603907
VISIT DATE: 10/31/2022
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Common Areas: These included the living room, dining area and den. The common areas were properly furnished. Floors were clean and maintained and furniture is in good repair. Living room has a fireplace but is not in use. Staff work station is in the den and was clear of clutter. Properly labeled medications were locked in a cabinet at the dining room area.

Surrounding Grounds: Entry/exits were free of obstruction. The back yard has an open patio with furniture appropriate for outdoor use. The garage was locked and being used for storage. LPA observed a shed locked and being used for storage. The outdoor area, front and back yards were free of hazards. LPA observed two side gates closed and unlocked. The laundry area and detergents is located by the kitchen. No chemicals, detergent, cleaning supplies observed accessible to the clients in care.

Resident Files: LPA conducted a file review of client records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. An exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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