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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606019
Report Date: 11/13/2024
Date Signed: 11/13/2024 02:03:59 PM

Document Has Been Signed on 11/13/2024 02:03 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 IIIFACILITY NUMBER:
197606019
ADMINISTRATOR/
DIRECTOR:		AMALIA SANDOVALFACILITY TYPE:
735
ADDRESS:747 WHITLATCHTELEPHONE:
(661) 945-5277
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
11/13/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Linda HughesTIME VISIT/
INSPECTION COMPLETED:
02:15 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 9:20 am and was greeted by staff member. Administrator arrived shortly after LPA arrival and was informed of the purpose of the visit. Entrance interview conducted. Staff informed LPA that all clients were currently attending day program.

A tour of the physical plant was conducted with Administrator at 09:30 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) ambulatory clients.

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

Kitchen: LPA conducted tour at the kitchen around 09:40 am 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 objects, medications, and chemicals being locked and inaccessible to clients in care.

Common Areas: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 71°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 12:30 pm. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full and last serviced on 10/04/2023. Staff and client files were observed to be locked and inaccessible to clients in care.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/13/2024
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 III
FACILITY NUMBER: 197606019
VISIT DATE: 11/13/2024
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Bedrooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.

Bathrooms: At 10:00 am LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 107.5 degrees F.

Garage: LPA observed the garage to be attached to the facility and currently being used for extra storage. LPA observed washer and dryer in the garage with detergents and chemicals locked in a cabinet.

Physical environment: LPA toured the outside area of the facility at 10:15 am. LPA observed appropriate outdoor furniture, with an umbrella for shade for clients. No bodies of water on the premises.

Administrative: LPA collected the LIC500, Bond, and Client roster. Annual fee is current.

Client & Staff Files: LPA conducted a file review of client and staff records at 11:00 am.



Medications: At 01:00 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Staff and Client Interviews: At 01:30 pm LPA interviewed staff present in the home.

No citations issued. Exit interview conducted. A copy of report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/13/2024
LIC809 (FAS) - (06/04)
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