<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607040
Report Date: 04/08/2022
Date Signed: 04/15/2022 04:40:19 PM

Document Has Been Signed on 04/15/2022 04:40 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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:
04/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:30 PM
MET WITH:LINDA HUGHES, ADMINISTRATORTIME COMPLETED:
03:50 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Shira Stamps met with Administrator Linda Hughes for an unannounced one (1) year Required visit for this facility. LPA arrived at 2:30 pm and was greeted by caregiver, Kadesia Hill. The Administrator was called at 2:38pm, and the caregiver informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed the facility mitigation plan (approved on 03/13/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was properly screened by the Caregiver.

A tour of the physical plant was conducted with the Caregiver at 2:45pm. The Administrator arrived at 2:55pm and finished the rest of the tour. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients.

Living and dining
At 2:47 pm, LPA observed the living room and family room area to be neat and clean along with the dining room. LPA observed the locked medication cabinet for extra medications and client files. The facility maintains a comfortable temperature at 75°F. There is one (1) fire extinguisher located in the kitchen. The smoke detector and fire extinguisher were serviced on 3/31/22 by Fletcher Fire Protection. The carbon monoxide detector was tested and observed to be operational at 3:03 pm.

CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 04/08/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Food Inspection
LPA conducted a tour of the kitchen around 2:45 pm and observed a supply of seven-day non-perishable and two day perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides, detergents and/or toxins are stored in the cabinet below the kitchen sink and were locked and inaccessible to clients. Knives, sharp objects, and medication are also locked in a kitchen cabinet.

Bathrooms
At 2:50 pm LPA observed all bathrooms to have non-skid matts and the appropriated wash your hands signs posted in the bathroom. Hot water was tested and measured within regulation at 117.4 degrees F.

Resident Rooms
At 2:48 pm, LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident.

Laundry
At 2:48 pm, LPA observed the laundry room. LPA observed detergents and cleaning supplies in the locked cabinet. LPA observed extra liens in a cabinet located in the hallway.

Garage
At 2:49 pm, LPA observed the attached garage, used for storage and 90-day supply of PPE. LPA observed locked cabinets for chemicals/toxins and extra food supply.

Physical environment
LPA toured the outside area of the facility at 2:52 pm. LPA observed appropriate outdoor furniture. There are no bodies of water on the premises.

Administrative: Annual fee is current.

An exit interview was conducted, and a copy of this report and appeal rights were given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 04/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2