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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607424
Report Date: 06/18/2022
Date Signed: 06/19/2022 07:19:26 AM

Document Has Been Signed on 06/19/2022 07:19 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:POWELSON HOME VFACILITY NUMBER:
197607424
ADMINISTRATOR:FELY POWELSONFACILITY TYPE:
735
ADDRESS:7616 MCNULTY AVENUETELEPHONE:
(818) 348-0351
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 6DATE:
06/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:01 PM
MET WITH:Robert Dela Cruz - StaffTIME COMPLETED:
03:30 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Robert Dela Cruz and purpose of the visit stated. LPA observed that three (3) residents were at the facility during visit and the other three (3) were working per the staff.

A tour of the physical plant was conducted at 12:15 PM and the following was noted:

The front main door is the only entrance being utilized at the facility. There is a sign on the front main door that everyone entering at the facility must be screened. Screening area is located immediately before and upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask.

The facility had submitted and approved Mitigation Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the garage.

Facility has four (4) private client bedrooms (2 private and 2 shared) and has three (3) bathrooms. Additional one (1) bedroom is designated for staff use. There is no body water in the facility.

(continued to LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELSON HOME V
FACILITY NUMBER: 197607424
VISIT DATE: 06/18/2022
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(continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.

Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at a range of 112.6°F to 119.2°F and within the required range.

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.

Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.

Fire extinguisher - The fire extinguishers are located in the kitchen and at the hallway upstairs. Extinguishers were observed to be operable and last inspected on 05/11/22. Smoke alarms were hardwired and inter connected, tested and observed to be operational. There is a carbon monoxide installed at the facility. Temperature of facility wall thermostat was set at 74°F and observed to be within the required range.

Garage is attached to the house and was observed to be locked during visit. Garage is also being used as Laundry area, PPE and other supplies storage. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area in the garage. Knives and sharps were also kept in a locked drawer in the kitchen.

Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There is a complete First Aid kit inside the medication cabinet.



There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/18/2022
LIC809 (FAS) - (06/04)
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