197604475-2-10-2025-31-AS-LCAS-DDRQ4F-20250210105016

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604475
Report Date: 02/10/2025
Date Signed: 02/10/2025 10:50:41 AM

Document Has Been Signed on 02/10/2025 10:50 AM - 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 II		FACILITY NUMBER:	197604475
ADMINISTRATOR/ DIRECTOR:	LINDA HUGHES		FACILITY TYPE:	735
ADDRESS:	1745 LIGHTCAP		TELEPHONE:	(661) 945-0375
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 4	DATE:	02/10/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Linda Hughes		TIME VISIT/ INSPECTION COMPLETED:	11:05 AM

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At 09:40 a.m. on 02/10/2025, Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced case management visit to this facility. LPA Casillas met with Quality Assurance (QA) Andrea Messina from North Los Angeles Regional Center at the facility. LPA and QA met with the Administrator Linda Hughes and disclosed the reason for the visit.

LPA and QA were greeted by staff member and were granted access. Entrance interview conducted.

Today’s case management visit is to follow up on an incident previously reported on 02/04/25 by the facility in which clients and staff members were locked out of the facility due to the security screen being locked and no one having a key. Client #1 (C1) offered to enter the facility through a bathroom window that was not locked and with assistance C1 was able to reach the window and proceeded to enter the facility. Once C1 was midway through the window C1 gave the ok to be released, it is then that C1 lost their balance and landed in the bathtub. C1 expressed that C1’s left arm was injured. Staff checked C1’s arm and there were no signs of redness, bruising, or swelling. Per the SIR, C1 was given an ice pack and went to lay down. A few minutes later C1 continued about their day expressing mild discomfort. The following day, C1’s arm displayed swelling and bruising and staff proceeded to take C1 to the emergency room where C1 was diagnosed to have fractures. The purpose of the visit is to obtain additional information regarding this incident.

Continued on 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

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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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 II	FACILITY NUMBER: 197604475
	VISIT DATE: 02/10/2025

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Interview with Administrator revealed that on 02/02/25 all clients and staff had gone on an outing and upon returning it was noticed that the security screen door was locked. Administrator stated that the key had been misplaced and no one else had a replacement key. Administrator admitted that there was no call placed to a locksmith or to the facility handyman to unlock the door. Administrator stated that C1 offered to jump through the window since C1 is of thin build and would seemingly fit through the opening. Administrator and Staff #1 (S1) proceeded to assist C1 in climbing the wall by giving C1 a boost and C1 was able to successfully enter the bathroom, but not before being released and falling into the bathtub. Per the Administrator, C1 mildly complained about pain in C1’s left arm and was offered an ice pack as there was no visible sign of swelling or bruising. C1 continued about their day and only complained of mild discomfort. The following day there was noticeable swelling and C1 was taken to the Emergency room where C1 had x-rays to verify multiple fractures on the left arm that C1 landed on when falling. LPA Casillas reviewed hospital discharge paperwork provided with the SIR and there were four (4) different fractures to include C1’s left wrist, forearm, and elbow. Due to information and documentation provided, citations will be issued with a civil penalty for C1’s injuries. During visit Administrator showed LPA and QA that all locks had been serviced and had appropriate keys and spare keys made.

Citations issued. Civil penalty issued. Appeals rights discussed and provided. Exit interview conducted. A copy of report given to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/10/2025 10:50 AM - It Cannot Be Edited

Created By: Lorena Casillas On 02/10/2025 at 10:29 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 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: 02/10/2025

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 02/11/2025 Section Cited CCR 80072(a)(2)	1 2 3 4 5 6 7	Personal Rights(a)...each client shall have personal rights which include, but are not limited to, the following (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment to meet his/her needs. This was not met as evidenced by:	1 2 3 4 5 6 7	Administrator discussed and agreed to vendorized training on Personal Rights for all staff. Additionally, Administrator will submit a written letter certifying that, moving forward, they will ensure to follow and adhere to CCR 80072.
	8 9 10 11 12 13 14	Based on interviews and record reviews, facility staff failed to ensure that C1’s personal rights were protected in which staff did not accord C1 safety by allowing C1 to climb through a bathroom window causing C1 fractures. This poses an immediate health and safety risk to clients in care.	8 9 10 11 12 13 14	Proof attendance with staff signatures and written letter shall be emailed to LPA by POC due date.
Type B 02/10/2025 Section Cited CCR80087(a)	1 2 3 4 5 6 7	Buildings and Grounds (a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.	1 2 3 4 5 6 7	During LPA visit Administrator was able to show LPA that all locks have been serviced and have proper keys. POC was cleared at the time of visit.
	8 9 10 11 12 13 14	Based on interviews and observations, the facility staff failed to have keys or spare keys to facility doors causing clients and staff to be locked out. This poses a potential health and safety risk to clients in care.	8 9 10 11 12 13 14

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Lorena Casillas

LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2025

LIC809 (FAS) - (06/04)

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