197607040-8-6-2024-31-AS-RORN-D98UE6-20240918153038

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197607040
Report Date: 08/06/2024
Date Signed: 08/06/2024 03:20:40 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.RO, 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
08/01/2024 and conducted by Evaluator Lorena Casillas

COMPLAINT CONTROL NUMBER: 31-AS-20240801084619

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:	08/06/2024
		UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Linda Hughes		TIME COMPLETED:	03:35 PM

ALLEGATION(S):

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Staff did not prevent a resident from physically harming another resident while in care.

INVESTIGATION FINDINGS:

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On 08/06/2024 at 09:45 am Licensing Program Analyst (LPA) Lorena Casillas conducted an unannounced complaint visit to investigate the above stated allegation. LPA met with Administrator Linda Hughes and explained the reason for the visit.

LPA Casillas arrived at facility and there was no answer at the door. LPA Casillas called Administrator so that they could meet LPA at facility. Administrator arrived shortly after. There were no clients present as they were all at day program and will be returning to the facility at 2:00 pm.

At 10:00 AM LPA Casillas conducted a physical plant tour with Administrator. During the investigation, record reviews were conducted from 10:30 am to 12:00 pm. LPA requested resident roster, LIC 500, Administrator Certificate and Bond Certificate. LPA requested copies of pertinent information relevant to the investigation including but not limited to, resident records, and any other information pertaining to resident care. LPA conducted interviews from 1:00 pm to 3:00 pm. Continued on LIC9099-C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

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

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20240801084619

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

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

FACILITY NAME: POWELL HOUSE IV	FACILITY NUMBER: 197607040
	VISIT DATE: 08/06/2024

NARRATIVE

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Allegation: Staff did not prevent a resident from physically harming another resident while in care.

It is alleged that staff did not prevent a resident from physically harming another resident while in care. Regarding this allegation it is reported that on 7/29/24 Client #1 (C1) was attacked by Client #2 (C2) causing scratches to C1’s face, forehead, left ear, back and knees from falling into bushes during the physical altercation. LPA interviewed Administrator and it was revealed that that there was an altercation between C1 and C2. Administrator states that staff were present and did not leave clients alone. Administrator states that staff was in presence of clients while they were waiting for C1’s ride for day program, however, C2 yelled at C1 and C1 attacked C2. While engaged in the altercation, S1 was able to successfully separate the clients but not before C1 fell into the bushes causing his injuries. Interview with Staff #1 (S1) revealed that S1 was present when the altercation took place between C1 and C2. S1 states that it happened fast, there was shouting at first and then C1 attacked C2 after C2 yelled at C1 to go back inside the house because C1’s ride was not there yet. S1 states that C1 was the one that initiated the altercation not C2, furthermore S1 states that S1 stood in between the clients but C1 was able to maneuver around S1 to get to C2. S1 also states it was not negligence on S1’s part, it was simply that the incident happened really fast, and the altercation was unavoidable. LPA interviewed Staff #2 (S2) and S2 stated that S2 was not present at the time of the incident but expressed that C2 has been confrontational with all clients in the facility causing conflict amongst them. LPA interviewed C1 but C1 denied the incident happening at all. LPA attempted to interview C2 however, C2 declined to be interviewed and stated that C2 was not interested in speaking with LPA. LPA reviewed special incident report that corroborates that although C2 initiated the verbal confrontation, C1 is the one that attacked C2. Therefore, based on observations, record reviews, and interviews this allegation that staff did not prevent a resident from physically harming another resident while in care is deemed Unsubstantiated.

No citations issued. Exit Interview conducted. A copy of the report given to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 08/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/06/2024

LIC9099 (FAS) - (06/04)

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