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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606438
Report Date: 12/10/2024
Date Signed: 12/10/2024 06:27:41 PM

Document Has Been Signed on 12/10/2024 06:27 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:POWELSON HOME IVFACILITY NUMBER:
197606438
ADMINISTRATOR/
DIRECTOR:		FELY POWELSONFACILITY TYPE:
735
ADDRESS:22313 BASSETTTELEPHONE:
(818) 737-7253
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
12/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:27 PM
MET WITH:Ruth Ramos - AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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A Required One (1) year visit is conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Ruth Ramos and purpose of the visit stated. This is a North Los Angeles Regional Center (NLARC) vendored facility Level II.

A tour of the physical plant was conducted at 3:42 PM and the following was noted:

The front main door is the only entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation Plan and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted indoors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage.

The facility has four (4) private client bedrooms and two (2) bathrooms. Additional one (1) bedroom is designated for staff use. There is no body of water in the facility.

Fire extinguisher - The fire extinguisher is located in the kitchen. Extinguisher was observed to be operable and last bought on 07/14/24. Smoke alarms were hardwired and inter connected, tested and observed to be operational. There is a carbon monoxide installed at the facility. Temperature of facility wall thermostat was set at 74°F and observed to be within the required range.

(continued to LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELSON HOME IV
FACILITY NUMBER: 197606438
VISIT DATE: 12/10/2024
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(continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have sufficient supply of clean linen and towels.

Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at a range of 112.3°F to 118.9°F and within the required range.

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.

Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.

Garage: There is no garage at the facility, only car port at the front. There is a locked cabinet at the car port being used as storage for decors, PPE and other supplies. Laundry area is located in the kitchen. Detergents and other cleaning agents and toxins are kept locked in a cabinet near the dining area. Knives and sharps were also kept in a locked drawer in the kitchen.

Medication was observed to be inaccessible and stored in a secured steel medication cabinet in the dining area. There is a complete First Aid kit inside the medication cabinet.



Disaster drill was last conducted on 11/17/24. Required posting are observed to be complete and current and displayed properly at the facility.

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024
LIC809 (FAS) - (06/04)
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