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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606019
Report Date: 12/13/2023
Date Signed: 12/13/2023 02:44:19 PM

Document Has Been Signed on 12/13/2023 02:44 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:POWELL HOUSE IIIFACILITY NUMBER:
197606019
ADMINISTRATOR:AMALIA SANDOVALFACILITY TYPE:
735
ADDRESS:747 WHITLATCHTELEPHONE:
(661) 945-5277
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
12/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Amalia Sandoval and Monica JacksonTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an Annual Required visit and inspection of the facility. LPA met with administrator Amalia Sandoval and explained the reason for the visit. Administrator could not stay to sign todays report and designated staff Monica Jackson to sign todays report.

LPA and administrator took a tour of the physical plant of the facility and LPA observed the following:

The home is a one story building. Annual fees are current. The facility has fire clearance for four (4) ambulatory clients. Upon entry LPA observed required postings on facility wall.

Common Areas: These included the living rooms and dining area. The common areas were properly furnished, clean and clear of clutter. Dining table and couches were in good repair and sit the capacity of the facility. According to administrator facility sits two clients at a time at dining table for infection control during flue season.

Kitchen: The kitchen appliances and fixtures were maintained clean. LPA observed the facility to have a sufficient amount of 7 day non-perishable and 2 day perishable food; properly stored. Knives and sharps are kept locked in a kitchen cabinet in a tool box that can also lock.

Bedrooms: There are four (4) client bedrooms, for single use. Client bedrooms were observed to be appropriately furnished with appropriate bedding, linens, furniture and have sufficient lighting.

Bathrooms: There are two (2) bathrooms in the facility. One (1) bathroom is in a client's bedroom for private use. Both bathrooms were properly supplied with toilet paper, hand soap and paper towels. Hot water temperature was measured at 111.8 degrees Fahrenheit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELL HOUSE III
FACILITY NUMBER: 197606019
VISIT DATE: 12/13/2023
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The smoke alarms are hardwired and interconnected. The facility has (2) two carbon monoxide detector in the dining area. Detectors were tested at 11:45 a.m. and were observed operational. LPA observed one (1) fire extinguisher fully shared with serviced date of 10/16/2023 by the kitchen.

Closet: There are (2) hallway closets where the facility stores extra linens.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. LPA observed a table with an umbrella for shade. The outdoor area was free of hazards.

Garage and Laundry: The garage is attached and is kept locked. The laundry area which includes a washer and dryer is in the garage. The washer is currently not functioning. Administrator states a technician came to the facility and ordered a part for the washer and will be servicing the appliance. Staff are currently washing clothes at a local Laundromat. The detergents are kept locked on cabinets above the washer and dryer. Extra facility supplies such as cleaning chemicals are kept locked in a cabinet. LPA observed emergency supply of food, water and an overflow of paper towels and toilet paper in the garage.

Client/Staff Records: At approximately 12:20 p.m. four (4) out four (4) client records and three (3) staff records were reviewed to insure compliance with licensing forms.

Medications: Medications and records were observed locked in a kitchen cabinet. Medication Records were reviewed for proper documentation. Medication records are maintained manually and facility also maintains Medical Administration Records (MAR).


Pursuant to Title 22 Division of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 12/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/13/2023
LIC809 (FAS) - (06/04)
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