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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607040
Report Date: 08/30/2022
Date Signed: 08/30/2022 05:15:23 PM

Substantiated


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 IVFACILITY NUMBER:
197607040
ADMINISTRATOR:LINDA HUGHESFACILITY TYPE:
735
ADDRESS:43669 E. 6TH STREETTELEPHONE:
(661) 729-2454
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 3DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Linda Hughes, Administrator TIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff yells at clients in care
INVESTIGATION FINDINGS:
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On 8/30/22, at 4:00pm, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations. The Administrator arrived at 4:15pm. Entrance interview conducted with the Administrator.

On 06-30-2022 LPA initiated the complaint investigation and conducted a physical plant tour, collected copies of relevant documents, and began interviews with clients and staff members. On 7/05/22, LPA delivered findings for five (5) out of seven (7) allegations. LPA conducted additional interviews and phone interviews for additional information.
Allegedly staff yelled at Client #1 (C1) to not grab food from the kitchen, and it is alleged that staff constantly yell at clients. Three (3) out of five (5) staff members interviewed indicated that they follow the client’s behavior plans and redirect the clients without yelling, and they have not heard staff yell at clients. Interviews with two (2) out of five staff members indicated that staff yells at the clients. CONTINUED...
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
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: 08/30/2022
NARRATIVE
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Additional interviews were conducted with the clients without the presence of the alleged staff members that yell at the clients, and three (3) out of four (4) clients indicated that yells at the clients and will cuss at the clients. It was found that staff have yelled at clients to “go to their room”, and staff have called clients “Nasty Ass.” Based on interviews it was found that staff yells at clients and speaks to them inappropriately, therefore the allegation, “staff yells at clients in care”, is deemed substantiated.

Exit interview conducted. Citation issued. Appeal rights and report delivered to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 5
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 IVFACILITY NUMBER:
197607040
ADMINISTRATOR:LINDA HUGHESFACILITY TYPE:
735
ADDRESS:43669 E. 6TH STREETTELEPHONE:
(661) 729-2454
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 3DATE:
08/30/2022
UNANNOUNCEDTIME BEGAN:
04:00 PM
MET WITH:Linda Hughes, AdministratorTIME COMPLETED:
05:20 PM
ALLEGATION(S):
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Staff refused to provide transportation to client in care
INVESTIGATION FINDINGS:
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On 8/30/22, at 4:00pm, Licensing Program Analyst (LPA) Shira Stamps conducted a subsequent complaint visit to deliver the findings of the above allegations. The Administrator arrived at 4:15pm. Entrance interview conducted with the Administrator.

On 06-30-2022 LPA initiated the complaint investigation and conducted a physical plant tour, collected copies of relevant documents, and began interviews with clients and staff members. On 7/05/22, LPA delivered findings for five (5) out of seven (7) allegations. LPA conducted additional interviews and phone interviews for additional information.

On 5/3/22, it was reported to Community Care Licensing that staff and clients got into a car accident. It is alleged that the car accident took place on 3/3/22, and C1 complained of neck and back aches resulting in C1’s physician scheduling physical therapy. It is alleged that staff refused to take C1 to the therapy sessions. Staff members interviewed indicated they transport clients to all medical appointments. CONTINUED...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
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: 08/30/2022
NARRATIVE
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 It was also indicated by two (2) out of five (5) staff members that C1 was not complaining of any pain after the accident and was observed to have normal behavior. Three (3) out of five (5) staff members indicated C1 was complaining of pain and received Tylenol for the pain. LPA reviewed C1’s medication log and found that on 5/7/22, 5/8/22; 5/9/22;5/13/22; and 5/29/22 C1 received Tylenol for head, neck, and back pain. Four (4) out of five (5) staff members indicated physical therapy was not prescribed by C1’s doctor, and they were unaware that C1 was receiving physical therapy. One (1) out of five (5) staff members indicated that C1’s mother retained a lawyer for the car accident and the lawyer came by the facility requesting that staff take C1 to physical therapy appointments. The staff interviewed indicated the lawyer was told staff could not take C1 to the physical therapy appointments due to the place being far away. Three (3) out of four (4) clients indicated that staff take them to all medical appointments. LPA reviewed the discharge paperwork from the hospital, and it was recommended for C1 to take Tylenol or Ibuprofen for pain and to follow up with their primary care doctor. The Administrator stated C1 had an appointment on 4/05/22 with the primary care doctor, and was not prescribed physical therapy. Interviews with staff indicated C1 was not prescribed physical therapy, and staff take clients to all their medical appointments. Document review also indicated C1 was to take over the counter pain medicine for any pain, and was not prescribed physical therapy, therefore based on interviews and document review the allegation, “Staff refused to provide transportation to client in care,” is deemed unsubstantiated.

Exit interview conducted. Citation issued. Appeal rights and report delivered to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 4 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/06/2022
Section Cited
CCR
80072(a)(1)
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80072(a)(1) Personal Rights. To be accorded dignity in his/her personal relationships with staff and other persons

This requirement is not met as evidenced by:

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The Administrator stated they will provide training to all staff members regarding personal rights, and will provide training material and signatures of all staff members that have attended the training by the POC due date to the LPA.
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Based on interviews, the Licensee failed to ensure that clients were accorded with dignity in that it was found that staff yells at clients.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC9099 (FAS) - (06/04)
Page: 5 of 5