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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197607040
Report Date: 05/15/2024
Date Signed: 05/15/2024 02:26:06 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 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
04/17/2024 and conducted by Evaluator Jose Gary Tan
COMPLAINT CONTROL NUMBER: 31-AS-20240417113711
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: 4DATE:
05/15/2024
UNANNOUNCEDTIME BEGAN:
11:44 AM
MET WITH:Linda Hughes - AdministratorTIME COMPLETED:
02:30 PM
ALLEGATION(S):
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Staff spoke inappropriately to resident
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced subsequent complaint visit at this facility to further investigate the above allegation. LPAs met with administrator Linda Hughes and explained the reason for the visit.

LPAs conducted physical plant tour at 12:00 PM, requested additional facility documents relevant to the investigation at 12:18 PM and reviewed the same from 12:20 to 1:00 PM. LPAs also conducted interviewed with residents between 1:45 PM to 2:15 PM. It was alleged that Staff #1 (S1) told Resident #1 (R1) inappropriate words such as "I'ma dog walk you" etc. LPA's interview with the Administrator on 04/23/24 at around 12:00 PM, revealed that it was R1 who told the same exact words to the police when R1 was interviewed by the police, and it was R1 who called the police. LPA's interview with S1 revealed that it was R1 who threaten S1 and other clients and staff at the facility all the time. S1 denied cussing R1 or any other resident at the facility as R1 has been the house manager of the facility for the last twenty (20) years and never cussed any client at any time during S1's tenure at the facility. (continued on LIC 9099-C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
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 2
Control Number 31-AS-20240417113711
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: POWELL HOUSE IV
FACILITY NUMBER: 197607040
VISIT DATE: 05/15/2024
NARRATIVE
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(continued from LIC 9099)

Further, S1 added that when R1 ran out of cigarette about a week ago, R1 got mad at S1 and started cussing S1 who just walked away but R1 called the police. LPAs' record review today between 12:20 PM to 1:00 PM revealed that R1 had a long history of verbal aggression, noncompliance, inappropriate behavior, AWOL, fabricating repetitive statements and making false accusations. LPAs' interview with three (3) residents today between 1:45 PM to 2:15 PM also revealed that all of them did not experience being cussed by any staff nor witnessed any staff speaking inappropriately or cussing any resident at any time.

Based on the information gathered during this and prior visit, the allegation is deemed unsubstantiated at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024
LIC9099 (FAS) - (06/04)
Page: 2 of 2