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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604475
Report Date: 08/25/2021
Date Signed: 08/25/2021 04:54:29 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
11/16/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20201116113302
FACILITY NAME:POWELL HOUSE, INC IIFACILITY NUMBER:
197604475
ADMINISTRATOR:DWAYNE POWELLFACILITY TYPE:
735
ADDRESS:1745 LIGHTCAPTELEPHONE:
(661) 945-0375
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 3DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Linda HughesTIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Staff not supervising resident resulting in resident wandering away from facility.

Staff not supervising resident resulting in resident engaging in inappropriate activities/behavior
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unnanounced complaint investigation and arrived at the facility at 1:00pm. Upon approaching the front door LPA observed the COVID-19 signs. LPA was greeted by Linda Hughes, Administrator, who was wearing a mask. Administrator took LPA's temperature and asked COVID symptom questions. LPA stated the purpose of the visit is regarding the allegations listed above.

LPA was escorted by staff member, Lowanna Carr throughout the facility. LPA observed sign in area which contained the sign in sheet, thermometer, and hand sanitizer. LPA was escorted to the kitchen & observed an adequate supply of food in the refrigerator, freezer, and pantry. LPA observed the knives and cleaning supplies were locked in a kitchen cabinet. LPA observed the two bathrooms which contained wash your hands sign, hand soap, paper towels, and trash cans. LPA observed the staff room and observed the water heater had been moved out the office.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20201116113302
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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 II
FACILITY NUMBER: 197604475
VISIT DATE: 08/25/2021
NARRATIVE
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LPA walked outside in the backyard and saw the water heater outside.

LPA Spaeth interviewed five staff members who stated none of the allegations occurred at the facility. Therefore the complaint is unsubstantiated at this time.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 08/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2021
LIC9099 (FAS) - (06/04)
Page: 2 of 2