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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604475
Report Date: 02/08/2022
Date Signed: 02/08/2022 11:34:02 AM

Document Has Been Signed on 02/08/2022 11:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:13 AM
MET WITH:Linda Hughes, AdministratorTIME COMPLETED:
11:40 AM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Linda Hughes for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:13 am and was greeted by caregiver Lowana Carr. Two (2) residents were observed in the living room watching TV. The rest of the residents were observed to be in their room sleeping, watching TV and/or resting. The Administrator arrived at 10:25 am. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA Stamps reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the caregiver. LPA was asked to sign-in and sanitize/wash hands.

A tour of the physical plant was conducted with the Administrator at 10:27 am. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) residents. The facility is Fire Cleared for four (4) ambulatory.

Food Inspection
LPA conducted a tour of the kitchen around 10:27 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object locked under the kitchen sink and observed the medication cabinet locked and inaccessible to residents in care.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident. CONTINUED.....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/08/2022
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: POWELL HOUSE, INC II
FACILITY NUMBER: 197604475
VISIT DATE: 02/08/2022
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Bathrooms
At 10:33 am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted. Hot water was tested at 11:20 am and measured within regulation at 120.0 degrees F.

Laundry
At 10:34 am, LPA observed chemicals/hazardous items in a locked cabinet in the laundry room.

Physical environment
LPA toured the outside area of the facility at 10:35 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 73°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:37 am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 09/29/21. At 10:40 am, LPA observed the resident and staff files to be locked and inaccessible to residents in care.

Garage
At 10:35 am, LPA observed the garage to be attached to the facility and currently being used for an extra storage and PPE supplies.

Administrative: LPA collected the resident roster and the LIC.500. Annual fee is current.


An exit interview was conducted, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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