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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607424
Report Date: 12/19/2023
Date Signed: 12/19/2023 11:53:53 AM

Document Has Been Signed on 12/19/2023 11:53 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.ASC, 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: 4CENSUS: 2DATE:
12/19/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Robert Dela CruzTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a required annual inspection for the facility. LPA met with staff Robert Dela Cruz, who was informed the reason of the visit. Administrator was contacted and notified of the visit.

A tour of the physical plant was conducted. LPA observed Licensing required postings, as well as COVID signs. All smoke alarms and carbon monoxide were tested and functioning properly. Fire extinguishers were charged. Disaster drills are conducted every other month, the last disaster drill was conducted 09/26/2023.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; and food was properly stored and labeled. Medications were locked in a kitchen cabinet. Knives and sharps are stored in a locked kitchen drawer. There is an extra freezer and refrigerator in the garage, stocked with food.

Bedrooms: There were four bedrooms; (1) shared, (2) private and (1) room for staff. All bedrooms were properly furnished and had appropriate bedding and linens.

Bathrooms: There were three bathrooms designated for clients' use. All bathrooms were clean, properly supplied and had functional fixtures. LPA observed non-skid mats and grab bars. Hot water temperature was measured at 116.6 degrees Fahrenheit. There is soap and towels available.

Common Areas: These included the living rooms and dining area. The common areas were clean and properly furnished. There is a staff office with gym equipment for client's use.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELSON HOME V
FACILITY NUMBER: 197607424
VISIT DATE: 12/19/2023
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Surrounding Grounds: There was furniture appropriate for outdoor use. All passageways were free of obstruction. The laundry area was in the garage. Cleaning supplies and detergents are locked in a cabinet in the garage. Garage stores household and PPE supplies.

Resident Records: Clients files were reviewed; LPA checked resident files for updated appraisals. Clients are vaccinated and records were in files.

Cash Resources: Logs and cash resources were consistent; there were no discrepancies observed.

Medications: Medications are consistent with the logs on file. Doctor's orders for medications are in file. PRN log is maintained medications are given as prescribed.

Staff Records: Staff files included first aid certifications and staff have criminal record clearance; as well as current training records.

No deficiencies/Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023
LIC809 (FAS) - (06/04)
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