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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604475
Report Date: 05/22/2023
Date Signed: 05/22/2023 12:05:10 PM

Document Has Been Signed on 05/22/2023 12:05 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
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:
05/22/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:LoWana Carr, caregiverTIME COMPLETED:
12:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Shira Stamps with facility staff member Lowana Carr approximately 11:15 am for a case management visit. This case management visit was conducted currently with the complaint investigation this day.

Entrance and exit interview conducted over the phone with the Administrator. The Administrator stated caregiver LoWana Carr can sign the report.

The purpose of the case management is to check on the health and welfare of the clients in care and to issue deficiencies observed during the course of today’s investigation which are not related to the complaint. LPA conducted a physical plant tour of the backyard at 11:15 am and observed there to be multiple sharp old wooden fence pieces stored on the right side of the house. The sharp wooden pieces had multiple nails sticking out of them. Based on interviews the handyman fixed the backyard fence in March and in the beginning of May and was supposed to come this week to clean up the old materials. Based on observation sharp wooden pieces with nails are currently being stored on the side of the house and which poses an immediate health and safety risk to clients in care. At 11:35 am LPA asked a staff member to remove all the sharp wooden pieces and to store them in the locked garage until the handyman can come and remove them from the home. At 11:45am, LPA observed all sharp wooden pieces to be stored in the locked garage.

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 9099D included with this report.

Appeal rights issued. Exit interview conducted. Report Delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 05/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/22/2023
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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Document Has Been Signed on 05/22/2023 12:05 PM - It Cannot Be Edited


Created By: Shira Stamps On 05/22/2023 at 11:48 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: 05/22/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/23/2023
Section Cited
ILS
80087(c)

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80087(c) Buildings and Grounds. Outdoor and indoor passageways…open porches and other areas of potential hazard shall be kept free of obstruction.

This requirement is not met as evidenced by
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The caregiver immediately removed the pieces and stored them in the lock garage until the handyman will pick up the materials. The Administrator will provide LPA with verification that the materials have been picked up.
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Based on observation, Licensee did not keep the backyard free from obstructions. LPA observed multiple sharp wooden fence pieces with nails sticking out of the boards being stored on the side of the house.
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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:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 05/22/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/22/2023


LIC809 (FAS) - (06/04)
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