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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603907
Report Date: 11/27/2023
Date Signed: 11/27/2023 01:23:28 PM

Document Has Been Signed on 11/27/2023 01:23 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
CCLD Regional Office, 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: 3DATE:
11/27/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Celine TaylorTIME COMPLETED:
01:25 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility 9:30 am LPA was greeted by staff Celine Taylor and disclosed the purpose of the visit.

LPA conducted a tour of the physical plant at approximately 9:50 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living/dining room combination, kitchen, and den/office combination. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to have adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the three (3) residents currently residing there. Two (2) days of
perishable food observed. The freezer is stocked with meats and frozen vegetables. Resident medications are stored in wall mounted metal cabinet in dining area. Medications observed to be locked and inaccessible to residents in care. Sharps are locked in staff room, observed to be in accessible to residents. Toxins are stored and locked in pantry room, in main bathroom bottom cabinet and in garage. Toxins observed to be inaccessible to residents. There is one (1) fire extinguisher attached to wall in kitchen and observed to be charged.

Laundry room is located at end of kitchen next to exit door. The appliances observed to be clean and functional.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/27/2023
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: POWELSON HOME II
FACILITY NUMBER: 197603907
VISIT DATE: 11/27/2023
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(Cont. from 809)

The facility has a total of four (4) bedrooms and (2) bathrooms. There is one (1) staff room.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a supply of linens in hall closet and in shower only room.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 116.6 and 117.5 -degrees Fahrenheit.

Backyard has the following: Covered patio with tables and chairs. Patio furniture observed to be in good repair.

Attached Garage: Used for PPEs, toxins, and storage.

Shed: Locked shed used to store equipment/resident luggage

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 11:15 am, LPA reviewed two (2) staff files. Staff files had the appropriate training's to include current First aid and CPR. Three (3) resident files reviewed included medical assessments and current Individual Program Plans (IPPs).

No deficiencies noted.
Exit Interview Conducted /Copy of the Report given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023
LIC809 (FAS) - (06/04)
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