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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607040
Report Date: 11/30/2023
Date Signed: 11/30/2023 04:11:45 PM

Document Has Been Signed on 11/30/2023 04:11 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
WOODLAND HILLS S.RO, 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: DATE:
11/30/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Amalia SandovalTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with stand in Administrator Amalia Sandoval for an unannounced one (1) year Required visit for this facility.

LPA arrived at 9:30 am, there was no one in the home at the time. LPA called Licensee Shreda Powell and stated the purpose of the visit for today, she stated that current Administrator Linda Hughes is out on medical leave and that the stand in Administrator Amalia Sandoval would be arriving shortly. Administrator Amalia Sandoval arrived at 9:50am.

A tour of the physical plant was conducted with the Administrator at 10:15 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupied by three (3) clients.

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

Living and dining: At 10:24 am, LPA observed the living room and family room area to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was serviced on 10/16/2023. The carbon monoxide detector and smoke detectors were tested and observed to be operational at 10:35 am.

Continued....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/30/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/30/2023
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Kitchen: LPA conducted a tour of the kitchen around 10:30 am 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. Knives, cleaning supplies, pesticides, detergents and/or toxins are stored in the cabinet below the kitchen sink and were locked and inaccessible to clients. Medications are also locked in a kitchen cabinet along with a properly stocked first aid kit.

Bathrooms: At 10:35 am 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 117.6 degrees F.

Resident Rooms: At 10:40 am, LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each resident.

Laundry: At 10:42 am, LPA observed the laundry room. LPA observed detergents and cleaning supplies in the locked cabinet. LPA observed extra linens in a cabinet located in the hallway.

Garage At 10:43 am, LPA observed the attached garage, used for storage and an extra supply of PPE. LPA observed locked cabinets for chemicals/toxins. LPA observed an extra food supply.

Physical environment: LPA toured the outside area of the facility at 10:45 am. LPA observed appropriate outdoor furniture and shading. There are no bodies of water on the premises.

Administrative: LIC 500 and client roster collected. Annual fee is current.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms at 10:50 am. LPA observed that Admissions Agreement for one (1) established client was not in the client folder, Administrator nor Licensee were able to provide it.



Staff Files: LPA conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms at 11:06 am.
Continued....
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 11/30/2023
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Cash Resources: LPA was informed that the licensee handles cash for all three (3) clients. LPA reviewed cash resources for the three (3) clients at 3:08 pm. Logs and cash resources did not match for the 3 clients. Money is kept in one bank account for the clients and the amount indicated does not match the total for the 3 clients on their LIC 405 forms and cash on hand. Additionally, clients are not initialling the LIC 405 form when money is used from their accounts. Administrator will be purchasing a safe by 12/07/23 in order to avoid this from happening again and will go to the bank to get all the client funds to store them individually at the facility.

Medications: At 12:20 pm LPA and Administrator reviewed medication and medication records for proper documentation.

Staff Interviews: At 12:55 pm LPA interviewed staff.

Client Interviews: LPA was not able to interviewed clients as they were out in day programs.

The following deficiencies were observed (See LIC 809-D) and cited. Failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were discussed and provided to Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 11/30/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 11/30/2023 04:11 PM - It Cannot Be Edited


Created By: Lorena Casillas On 11/30/2023 at 03:20 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: POWELL HOUSE IV
FACILITY NUMBER: 197607040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/30/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80068(a)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement with each client and the client's authorized representative, if any.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in one (1) out of three (3) clients by not having the admissions agreement in the client file which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/01/2023
Plan of Correction
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Administrator contacted Regional Center in order to get a copy of the Admissions Agreement that was missing. Administrator was able to get a copy and it was placed in client file while LPA was present.
Type B
Section Cited
CCR
80026(e)
(e) Cash resources, personal property, and valuables of clients shall be separate and intact, and shall not be commingled with facility funds or petty cash.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three (3) out of three (3) clients' P&I records, due to comingling clients funds which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 12/07/2023
Plan of Correction
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Administrator will purchase a safe and will to go bank to get client funds in order to keep said funds in the facility. The client funds will be separate and will be individually identified. Administrator will send a picture of the safe and the reciept of purchase by 12/07/23 along with a picture of the separate client funds in the safe.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Lorena Casillas
LICENSING EVALUATOR SIGNATURE:
DATE: 11/30/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/30/2023


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