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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610607
Report Date: 10/28/2024
Date Signed: 10/28/2024 01:06:58 PM

Document Has Been Signed on 10/28/2024 01:06 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 VFACILITY NUMBER:
197610607
ADMINISTRATOR/
DIRECTOR:		POWELL, DWAYNEFACILITY TYPE:
735
ADDRESS:2139 KETTERINGTELEPHONE:
(310) 413-3730
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 0DATE:
10/28/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:50 AM
MET WITH:Dwayne PowellTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/28/2024 at 09:50 am, Licensing Program Analyst (LPA) Lorena Casillas conducted an announced Pre-Licensing Inspection with Licensee Shreda Powell and Administrator Dwayne Powell. An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on 04/03/2024. A fire clearance was approved on 07/11/2024, for four (4) ambulatory clients for a total capacity of four (4). Bedrooms 1-4 are designated for ambulatory clients. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

The Component III presentation was conducted from 10:15 am until 12:15 pm with Licensee.

A tour of the physical plant was initiated at approximately 12:30 pm and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There will be an adequate supply of two (2) days perishable once clients are in the home. There was a seven (7) day supply of nonperishable food and dining ware to accommodate a maximum capacity of four (4). Knives will be locked under the kitchen sink within a locked box. Medication will be locked in a kitchen cabinet. The facility has one fire extinguisher that was fully charged on 08/19/2024 located in the kitchen. There is a first aid kit is in a kitchen cabinet and is equipped with the necessary supplies.

COMMON AREAS: These included the living room and dining room areas, which were equipped with living room furniture, a television, tables, and chairs. The dining room table is large enough to accommodate up to four (4) clients. There were no visible immediate hazards. The smoke alarms are hard wired and inter-connected and are functional. The carbon monoxide detector is functional. The facility temperature was at a comfortable 72 degrees Fahrenheit.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/28/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: POWELL HOUSE V
FACILITY NUMBER: 197610607
VISIT DATE: 10/28/2024
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BEDROOMS: There are four (4) bedrooms designated for client use. The applicant furnished the client’s bedrooms with beds, nightstand, chairs, dresser, bedding, and linen. All rooms have sufficient lighting.

BATHROOMS: The facility has three (3) bathrooms. All bathrooms were observed to have the proper fixtures, and non-skid mats. The hot water delivered in the bathrooms measured 113.1 degrees F.

LAUNDRY ROOM: Cleaning detergents and supplies are locked in the laundry room area.



GARAGE: The garage is used for storage. It holds emergency food containers and water.

STAFF/CLIENT RECORDS: Staff and client records will be stored in a locked cabinet, located in the dining room. The applicant was advised to ensure that client and staff records will be accessible to the licensing agency upon request or during inspection. Facility will have awake staff.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio with shade and backyard furniture. The facility backyard has sufficient yard space to accommodate outdoor activities. There is no swimming pool or bodies of water.

Exit Interview was conducted, and a copy of this report was emailed to applicant.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024
LIC809 (FAS) - (06/04)
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