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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607040
Report Date: 06/18/2024
Date Signed: 06/18/2024 11:52:46 AM

Document Has Been Signed on 06/18/2024 11:52 AM - 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/
DIRECTOR:		LINDA HUGHESFACILITY TYPE:
735
ADDRESS:43669 E. 6TH STREETTELEPHONE:
(661) 729-2454
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
06/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Linda HughesTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with stand in Administrator Linda Hughes for an unannounced one (1) year Required visit for this facility.

LPA arrived at 9:20 am and was greeted by staff members. Staff members called Administrator Linda Hughes and was told that they would be arriving shortly. Administrator Linda Hughes arrived at 9:30am.

A tour of the physical plant was conducted with the Administrator at 09:45 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) 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 09:45 am, LPA observed the living room and family room area to be neat and clean along with the dining room. Client files are locked in a file cabinet in the dining area. The facility maintains a comfortable temperature at 74°F. The carbon monoxide detector and smoke detectors were tested and observed to be operational at 10:00 am.

Kitchen: LPA conducted a tour of the kitchen around 09:50 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. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was serviced on 10/16/2023.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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: 06/18/2024
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Bathrooms: At 09:55 am LPA observed all bathrooms to have non-skid mats and the appropriated wash your hands signs posted in the bathroom. Hot water was tested and measured within regulation at 108.9 degrees F.

Resident Rooms: At 10:00 am, LPA observed rooms to have the appropriate bedding. There is a nightstand, chair and sufficient lighting for each resident.

Laundry: At 10:05 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 10:08 am, LPA observed the attached garage, used for storage, emergency food and an extra supply of PPE. LPA observed locked cabinets for chemicals/toxins.

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

Administrative: LIC 500, client roster, Administrator certificate and surety bond were emailed to LPA as the printer is down. Annual fee is not current. LPA asked Administrator to pay fee immediately. Administrator contacted Licensee who paid the fee and gave confirmation # 936637.

Resident Files: LPA conducted a file review of resident records at 10:30 am.



Medications: At 11:15 am LPA and Administrator reviewed medication and medication records.

Staff Files: LPA conducted a file review of staff records at 11:15 am.

Staff and Client Interviews: At 11:30 am LPA conducted interviews.

There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was emailed to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2024
LIC809 (FAS) - (06/04)
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