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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197606019
Report Date:
11/16/2022
Date Signed:
11/30/2022 08:27:00 AM
Document Has Been Signed on
11/30/2022 08:27 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 III
FACILITY NUMBER:
197606019
ADMINISTRATOR:
AMALIA SANDOVAL
FACILITY TYPE:
735
ADDRESS:
747 WHITLATCH
TELEPHONE:
(661) 945-5277
CITY:
LANCASTER
STATE:
CA
ZIP CODE:
93535
CAPACITY:
4
CENSUS:
4
DATE:
11/16/2022
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
10:15 AM
MET WITH:
Amalia Sandoval/ administrator
TIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) arrived at the home in order to conduct an infection control annual. The administrator was shopping when the LPA arrived but the LPA was able to get a hold of the administrator and she arrived a short while later.
The LPA had his temperature taken and all covid 19 questions asked. All residents was were at day program during the visit. The inspection tool was used to complete the visit. All smoke alarms were tested and functioned properly. There are 2 carbon monoxide detectors at the home and they functioned properly. The fire extinguisher was observed in the kitchen and was last serviced on 10/11/2022.
No deficiencies were observed during todays visit and the facility is currently following their infection control plan.
Exit interview conducted and report issued.
SUPERVISORS NAME
:
Nichelle Gillyard
LICENSING EVALUATOR NAME
:
Patrick Shanahan
LICENSING EVALUATOR SIGNATURE
:
DATE:
11/16/2022
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
11/16/2022
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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