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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607040
Report Date: 05/12/2025
Date Signed: 05/12/2025 02:59:37 PM

Document Has Been Signed on 05/12/2025 02:59 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/
DIRECTOR:		LINDA HUGHESFACILITY TYPE:
735
ADDRESS:43669 E. 6TH STREETTELEPHONE:
(661) 729-2454
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
05/12/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Linda HughesTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 05/12/25 Licensing Program Analyst (LPA) Lorena Casillas arrived at facility to conduct an unannounced one year required annual inspection for this facility. LPA met with stand in Administrator Linda Hughes. LPA arrived at 10:45 am and was greeted by staff member. Staff member called Administrator Linda Hughes and was told that they would be arriving shortly. Administrator Linda Hughes arrived shortly after, and an entrance interview was conducted.

A tour of the physical plant was conducted with the Administrator at 11:00 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 11:15 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 71°F. The carbon monoxide detector and smoke detectors were tested and observed to be operational.

Laundry: LPA observed detergents and cleaning supplies in the locked cabinet. LPA observed extra linens in a cabinet located in the hallway.

Continued on LIC809
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/12/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 05/12/2025
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Kitchen: LPA conducted a tour of the kitchen around 11:30 am and observed a supply of seven-day non-perishable and two-day perishable foods. Frozen foods are properly wrapped and stored. 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 10/01/2024.

Bathrooms: At 11:45 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 110.6˚ F.

Resident Rooms: At 12:00 pm, LPA observed rooms to have the appropriate bedding. There is a nightstand, chair, dresser/closet and sufficient lighting for each resident.

Garage At 12:25 pm, 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 12:35 pm. LPA observed appropriate outdoor furniture and shading. There are no bodies of water on the premises.

Administrative: LPA requested copies of LIC 500, client roster, Administrator certificate and surety bond. Annual fee is not due until 6/8/25.

Staff/Client Files: LPA conducted a file review of client and staff records at 12:45 pm.

Medications: At 02:45 pm LPA and Administrator reviewed medication and medication records.



Staff and Client Interviews: At 03:00 pm LPA conducted interviews.

No citations issued. Exit interviewed conducted and a copy of the report was given to the Administrator.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/12/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2025
LIC809 (FAS) - (06/04)
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