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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 05:06:24 PM

Substantiated


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
07/24/2020 and conducted by Evaluator Melissa Spaeth
COMPLAINT CONTROL NUMBER: 31-AS-20200724103454
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: DATE:
08/25/2021
UNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:TIME COMPLETED:
02:25 PM
ALLEGATION(S):
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Lack of supervision resulting in residents engaging in physical altercations
INVESTIGATION FINDINGS:
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LPA Spaeth conducted an unnanounced complaint investigation and arrived at the facility at 1:00 pm. Upon approaching the front door LPA observed the COVID-19 signs. LPA was greeted by LInda Hughes, Administrator and took LPA's temperature and asked COVID symptom questions. LPA stated the purpose of the visit is a complaint which states lack of supervision resulting in residents engaging in physical altercations.
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. LPA observed all bathrooms contained wash your hands sign, hand sanitizer and paper towels.
Substantiated
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 3
Control Number 31-AS-20200724103454
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 interviewed five staff members regarding the complaint and four of the five staff members stated had witnessed physical altercations between the two residents at the facility. Staff members stated there were times when staff were unable to redirect both residents and injuries occurred as a result of the altercations. LPA Spaeth received eight incident reports since January, 2020 which stated both R1 and R2 had engaged in physical altercations.

On January 10, 2020, LPA Kelly Dulek conducted a case management visit during a subsequent complaint visit for complaint control #31-AS-20191212170618 to take photos of proposed changes to facility space. LPA met with facility administrator Linda Hughes. Administrator Shreda Powell had contacted LPA Dulek and informed LPA of the intent to change the current staff office space into a functional client bedroom. Ms. Powell e-mailed a new facility sketch and LPA Dulek provided Ms. Powell with an LIC 9054 Local Fire Inspection Authority form. LPA toured the facility at 4:15 PM. Ms. Hughes informed LPA that the water heater will be relocated to outside the building as required prior to using the space as a client bedroom.

On 5/18/2020, LPA Spaeth conducted a case management – Incident visit in response to several incident reports that were sent to Community Care Licensing Division (CCLD). Administrator, Shreda Powell had stated staff were implementing activities to re-direct R1 and R2. On October 15, 2020, LPA Spaeth spoke to Shreda Powell (Administrator) at 10:00 am stating the purpose of the call was to discuss the number of incident reports describing physical altercations between R1 and R2. Administrator Powell stated there were issues with R1 and R2 because both residents share a room with each other. Administrator stated to LPA Spaeth that Administrator was planning to convert the office into a resident room. However, the office has not been converted into a resident room. Based upon staff interviews and the incident reports which state R1 and R2 obtained personal injuries while living at the facility, this complaint is substantiated at this time.

Pursuant to Title 22 California Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Exit interview conducted and a copy of the report along with the appeal rights provided to licensee via email.

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 3
Control Number 31-AS-20200724103454
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/25/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/25/2021
Section Cited
HSC
80072(a)(2)
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80072 Personal Rights (a)....each client shall have personal rights which include, but not limited to... (2) To be accorded safe, healthful & comfortable accomodations... to meet his/her needs.
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LPA Spaeth received a confirmed statement from Administrator Linda Hughes that R2 moved out of the facility as of July 19, 2021.
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This requirement is not met as evidenced by: Based on staff interviews and the incident reports CCL received from the facility, staff failed to provide a safe environment for R1 and R2.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
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 appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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