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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604475
Report Date: 01/08/2024
Date Signed: 01/08/2024 01:40:26 PM

Document Has Been Signed on 01/08/2024 01:40 PM - 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 IIFACILITY NUMBER:
197604475
ADMINISTRATOR:LINDA HUGHESFACILITY TYPE:
735
ADDRESS:1745 LIGHTCAPTELEPHONE:
(661) 945-0375
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
01/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Amalia SandovalTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Amalia Sandoval for an unannounced one (1) year Required visit for this facility.

LPA arrived at 09:50 am and there was no one at the facility. LPA proceeded to call Licensee Shreda Powell at 310-415-3999 and was told that staff would arrive shortly. The Administrator arrived at 10:15 am. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA Casillas reviewed facility mitigation plan (approved on 03/13/21) to make sure licensee was following current infection control recommendations.

A tour of the physical plant was conducted with the Administrator at 10:37 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. All residents were at day programs.

Food Inspection: LPA conducted a tour of the kitchen at 10:37 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. Food storage and preparation areas are 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. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 10/16/2023.

Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, chair, and sufficient lighting for each resident.

Continued 809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/08/2024
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: 01/08/2024
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Bathrooms: At 10:43 am LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 10:59 am and measured within regulation at 116.1 degrees F.

Laundry: At 10:44 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 10:45 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 68°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:47 am.

Garage: At 10:48 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.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 10:50 am.



Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:20 am.

Staff Interviews: At 11:45 pm LPA interviewed staff.

Client Interviews: LPA could not interview clients as they were not in the facility.

Medications: At 12:35 pm LPA and Administrator reviewed medication and medication records for proper documentation.

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

DATE: 01/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/08/2024
LIC809 (FAS) - (06/04)
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