197606438-10-27-2022-31-AS-MCAA-CKLPS9-20221027113359

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606438
Report Date: 10/27/2022
Date Signed: 10/27/2022 11:34:12 AM

Document Has Been Signed on 10/27/2022 11:34 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:	POWELSON HOME IV		FACILITY NUMBER:	197606438
ADMINISTRATOR:	FELY POWELSON		FACILITY TYPE:	735
ADDRESS:	22313 BASSETT		TELEPHONE:	(818) 737-7253
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 5	DATE:	10/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:59 AM
MET WITH:	Ruth Ramos		TIME COMPLETED:	11:40 AM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Ruth Ramos and explained the reason for the visit. At approximately 9:15am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are battery operated. The carbon monoxide detector functions properly. The fire extinguisher is located in the kitchen. The charge date is 5/26/2022. The last fire drill was conducted in September 2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There are a total of five (5) bedrooms in the home. Four (4) of the bedrooms are designated for residents' use. Each of the resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. The fifth bedroom is designated for staff use. Bathrooms: There are a total of two (2) bathrooms in the home which are all designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. No toxins or hazardous items observed as cleaning supplies is not kept underneath the kitchen sink Common Areas: These included the living room and dining area. The common areas were properly furnished. Floors were clean and maintained and furniture is in good repair. Staff work station is in between the resident and staff rooms. Properly labeled medications were locked in a cabinet at the dining room area.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: POWELSON HOME IV	FACILITY NUMBER: 197606438
	VISIT DATE: 10/27/2022

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. The back yard has an open patio with furniture appropriate for outdoor use. The outdoor area, front and back yards were free of hazards. The laundry area and detergents is located by the kitchen. No chemicals, detergent, cleaning supplies observed accessible to the clients in care.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. An exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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