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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197604475
Report Date: 08/23/2024
Date Signed: 08/23/2024 10:25:51 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 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
06/28/2023 and conducted by Evaluator Lorena Casillas
COMPLAINT CONTROL NUMBER: 31-AS-20230628091616
FACILITY NAME:POWELL HOUSE, INC IIFACILITY NUMBER:
197604475
ADMINISTRATOR:LINDA HUGHESFACILITY TYPE:
735
ADDRESS:1745 LIGHTCAPTELEPHONE:
(661) 945-0375
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 4DATE:
08/23/2024
UNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Linda HughesTIME COMPLETED:
10:45 AM
ALLEGATION(S):
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Staff did not prevent a physical altercation between clients
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Lorena Casillas conducted unannounced subsequent complaint visit to the facility to deliver final report. LPA was greeted by staff and was granted access, LPA called Administrator Linda Hughes, explained the reason for the visit and Administrator met with LPA shortly after.

Investigation of this complaint was conducted by LPA Antonia Alvizar-Ettima.

On 07/05/2023 Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an initial visit at which time LPA inspected the facility at approximately 11:38AM and observed one (1) client present at the facility. At 11:55AM LPA requested and reviewed facility records including but not limited to staff roster, clients’ roster, staff contact list, physician report, medical records, individual program plan, client(s) Identification Information, and In-House notes.

Continued on LIC9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
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-20230628091616
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 08/23/2024
NARRATIVE
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During initial visit between 11:48AM to 1:20PM LPA interviewed the Administrator, House Manager and one (1) out of three (3) clients who was present at the time of the visit.

On 08/12/24 at approximately 2:00PM LPA Alvizar-Ettima spoke with C1, C2 and two (2) facility staff over the phone.

Staff did not prevent a physical altercation between clients.

It is alleged that client (C1) was attacked by their roommate client (C2), staff didn’t help C1 when it was happening and didn’t do anything to prevent it.

Staff revealed that they always try to prevent altercation between clients. Staff denied C2 attacking C1. They indicated that C1 has aggressive behavior and was verbally aggressive towards C2, other clients and staff. Staff indicated that the altercation between C1 and C2 was sudden and unforeseen. Therefore, staff were unable to intervene immediately. The altercation between C1 and C2 happened in their bedroom and staff was in the doorway. Staff overheard C1 being verbally aggressive, yelling and screaming at C2. They intervened and C2 informed them that C1 bit C2 on their arm. Staff immediately called 911. Information revealed by C2 was consistent with the information revealed by staff. A review of facility records conducted on 08/12/24 verified information revealed by the facility staff.

Based on interviews and record review there is no pertinent information to verify the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.

No citations issued. Exit interview conducted. Copy of this report emailed to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC9099 (FAS) - (06/04)
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