197607040-7-5-2022-31-AS-NGID-CJ9W4R-20220914165753

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607040
Report Date: 07/05/2022
Date Signed: 07/05/2022 03:38:20 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

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

This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/23/2022 and conducted by Evaluator Shira Stamps

COMPLAINT CONTROL NUMBER: 31-AS-20220623114257

FACILITY NAME:	POWELL HOUSE IV		FACILITY NUMBER:	197607040
ADMINISTRATOR:	LINDA HUGHES		FACILITY TYPE:	735
ADDRESS:	43669 E. 6TH STREET		TELEPHONE:	(661) 729-2454
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 4	DATE:	07/05/2022
		UNANNOUNCED	TIME BEGAN:	02:40 PM
MET WITH:	Emma Chavez, Caregiver		TIME COMPLETED:	03:45 PM

ALLEGATION(S):

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Staff do not provide proper food service to clients in care
Staff changed client's primary physician without consent of client's authorized representative
Staff did not safeguard client's personal belongings
Staff forced client to get COVID-19 vaccination
Staff force clients to be in their bedroom for extended period of time

INVESTIGATION FINDINGS:

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On 7/5/22, at 2:40pm, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations. The Administrator was called at 2:40pm, and stated she was on the freeway, and stated the caregiver could sign the report for her. Entrance interview conducted with caregiver, Emma Chavez.

On 06-30-2022 LPA initiated the complaint investigation. At approximately 4:45 pm, LPA conducted a physical plant tour. From 3:40-4:00 pm LPA completed a record review of the client’s files and collected copies relevant documents. At 3:45 pm, LPA began interviews with two (2) out of two (2) staff members and two (2) out of four (2) clients. On 07-01-2022, LPA conducted additional phone interviews with the remaining two (2) clients.

CONTINUED...

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 5

Control Number 31-AS-20220623114257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POWELL HOUSE IV	FACILITY NUMBER: 197607040
	VISIT DATE: 07/05/2022

NARRATIVE

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It is alleged that staff serve junk food to clients and serve small portions of food. On 06-30-2022, LPA conducted a physical plant tour and observed the refrigerator, freezer, and cabinets to obtain fruits (bananas, apples, peaches, plums, yogurt, and mixed fruit); vegetables (salad, peas, corn, beats); meats (chicken, burgers, burritos, etc.) and starches (macaroni and cheese, waffles, pancakes, pudding, cinnamon rolls). LPA observed the menu to have a balanced diet of fruit, vegetable, protein, and a starch for the majority of the meals. Staff indicated every Friday the clients will choose which restaurant to eat out at. Interviews with staff indicated they offer alternative meals if clients do not want to eat what is on the menu. It was indicated by staff that C1 will choose to make noodles and not eat what is offered for a meal. Staff also indicated due to health concerns, some clients require portion control, and healthier alternative meals. Staff indicated clients have their rights, and staff can only provide the healthier options and cannot force clients to eat those options. Interviews with three (3) out of four (4) clients indicated staff provide a variety of meals, and indicated they receive enough food, and are able to ask for more food if they want it. Observations, interviews, and document review indicate clients are provided the option of a balanced diet, therefore the allegation, “Staff do not provide proper food service to clients in care,” is deemed unsubstantiated.

It is alleged that upon admission of C1, staff changed C1’s psychiatrist without consent from C1’s authorized representative resulting in C1 being prescribed medication that made C1 drowsy. Interviews with two (2) out of four (4) clients indicate staff would manage a change in physician if needed. Interviews with staff indicated staff have not changed the physician for any client in the home. It was indicated by staff that C1’s original psychiatrist left the clinic and C1 was given a new psychiatrist under the same clinic. LPA reviewed C1’s file and found all doctors remained the same since admission. Therefore, due to lack of supportive information the allegation, “Staff changed client's primary physician without consent of client's authorized representative,” is deemed unsubstantiated.

CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC9099 (FAS) - (06/04)

Page: 2 of 5

Control Number 31-AS-20220623114257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POWELL HOUSE IV	FACILITY NUMBER: 197607040
	VISIT DATE: 07/05/2022

NARRATIVE

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It is alleged that C1’s clothing keeps getting stolen and the authorized representative has to keep replacing the clothing. It is also alleged that C1’s phone was stolen at the facility. Interviews with three (3) out four (4) clients indicate personal items have not gone missing. Interviews with staff indicate no clients have informed staff that personal items have gone missing. LPA reviewed C1’s seven (7) pages of personal property and valuables lists. During the time of the investigation, LPA observed all of C1’s belongings had been packed and removed by C1. LPA was unable to verify if the items on the personal property and valuables lists were in C1’s possession. Therefore, due to lack of supportive information the allegation, “Staff did not safeguard client's personal belongings, “is deemed unsubstantiated.

It is alleged that C1 was forced to get the COVID-19 Vaccination and was told by staff that the vaccine was required in order to keep residing at the facility. Interviews with staff indicated clients had the option to refuse the vaccine. Two (2) out of four (4) clients indicated they received the vaccine to prevent from getting sick. Staff interviewed indicated no clients stated they did not want the vaccine. Staff indicated C1 received the first dose of the vaccine with no problem or issue and did not let staff know that C1 did not want the vaccine. Staff indicated after C1 received the first dose of the vaccine, C1 called their authorized representative (AR), and the AR was upset that C1 had received the vaccine. Staff indicated when it was time for the second does and booster shot, C1 still did not say that C1 did not want the vaccine. Interviews indicate clients were not forced to get the vaccine, therefore the allegation, “Staff forced client to get COVID-19 vaccination, “is deemed unsubstantiated.

It is alleged that staff force clients to stay in their room for almost the whole day, and clients are required to keep their room door open. During the investigation LPA observed two (2) clients sitting in the family room on their phone or reading a book. Interviews with staff indicate there is no policy indicating clients must keep their door open or closed. Document review of the house rules indicate there is no rule stating client’s doors must remain open. Interviews with three (3) out of four (4) clients indicate clients can close their door if they want to, and staff have no issues with that. Interviews with clients indicate clients are not forced in the rooms, and clients are able to sit in the family room or kitchen and socialize with others. Staff indicated clients normally have their doors closed when they are in their rooms, except for C1. Staff indicated C1 will keep the door open when in the room.

CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC9099 (FAS) - (06/04)

Page: 3 of 5

Control Number 31-AS-20220623114257

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POWELL HOUSE IV	FACILITY NUMBER: 197607040
	VISIT DATE: 07/05/2022

NARRATIVE

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Staff also indicated they will ask C1 to close the door if the TV is too loud. Staff interviews indicated clients watch TV or movies in the family room. Staff also indicated C1 will pace back and forth in front of the TV while other clients are watching TV, and staff will ask C1 to move away from the TV or go into their room. Interviews and observations indicate clients can keep their room doors open, and not forced to stay in their rooms. Therefore, based on interviews and observations the allegation, “Staff force clients to be in their bedroom for extended period of time,” is deemed unsubstantiated.

Exit interview conducted. Copy of report delivered to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 07/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/05/2022

LIC9099 (FAS) - (06/04)

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