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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604475
Report Date: 01/13/2025
Date Signed: 01/13/2025 03:14:04 PM

Document Has Been Signed on 01/13/2025 03:14 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/
DIRECTOR:		LINDA HUGHESFACILITY TYPE:
735
ADDRESS:1745 LIGHTCAPTELEPHONE:
(661) 945-0375
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
01/13/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Linda HughesTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Linda Hughes for an unannounced one (1) year Required visit for this facility.

LPA arrived at 11:50 am and was greeted by Administrator. LPA informed the Administrator of the purpose of the visit, entrance interview conducted.

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 12:00 pm. The facility has three (3) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory. All clients were out in the community.

Kitchen: LPA conducted a tour of the kitchen at 12:10 pm and observed there to be sufficient stock of two-day perishable and seven-day non-perishable 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 clients in care. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 10/01/2024.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2025
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: 01/13/2025
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Client Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, chair, and sufficient lighting for each client.

Bathrooms: At 12:20 pm LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 12:20 pm and measured within regulation at 116.1 degrees F.

Laundry: At 12:25 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 12:30 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. 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 69°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:30 pm.

Garage: At 12:35 pm, 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 client roster, bond certificate and LIC500. Annual fee is current.

Client Files: LPA conducted a file review of client records at 01:00 pm.



Staff Files: LPA conducted a file review of staff records at 02:00 pm.

Medications: At 02:30 pm LPA and Administrator reviewed medication and medication records.

Staff Interviews: At 2:50 pm LPA interviewed staff.

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

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: 01/13/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025
LIC809 (FAS) - (06/04)
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