<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608821
Report Date: 03/17/2022
Date Signed: 03/17/2022 09:44:38 AM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
03/07/2022 and conducted by Evaluator Shira Stamps
COMPLAINT CONTROL NUMBER: 31-AS-20220307100258
FACILITY NAME:WILLOUBEE RESIDENTIAL INC.FACILITY NUMBER:
197608821
ADMINISTRATOR:MARCUS WILLOUGHBYFACILITY TYPE:
735
ADDRESS:3559 EMERALD LANETELEPHONE:
(661) 941-9051
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 2DATE:
03/17/2022
UNANNOUNCEDTIME BEGAN:
07:35 AM
MET WITH:Jessica Hernandez, AdministratorTIME COMPLETED:
09:55 AM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Lack of care resulted in client covered with feces.
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Shira Stamps conducted an initial complaint visit to investigate the above allegation. LPA arrived at the facility at 7:35am and was greeted and screened by Caregiver Ashley Jewkes. At 8:15am, LPA met with Jessica Hernandez, the backup Administrator, to explain the reason for the visit and conduct an entrance interview.
LPA interviewed clients and staff from 7:40am-9:00am. Interviews with two (2) out of two (2) clients stated staff treat them very well. Interviews with three (3) out of four (4) staff members stated R1 has frequent accidents and will have behavior episodes when asked to clean up or shower after an accident. One (1) out of four (4) staff members stated R1 sometimes does not want to listen to prompts to shower but will eventually listen and take a shower after an accident. Four (4) out of four (4) staff members stated R1 had an accident and spread feces all over R1’s body, and R1 refused to shower after R1 had an accident. Interviews with four (4) out of four (4) staff members stated that R1 has a bathroom schedule due to having multiple accidents. Record review showed R1 will have behavior episodes when prompted to go to the bathroom or clean up after having an accident. CONTINUED...
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20220307100258
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: WILLOUBEE RESIDENTIAL INC.
FACILITY NUMBER: 197608821
VISIT DATE: 03/17/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The information obtained though record review and interviews showed that R1 refused to shower after spreading feces over R1’s body. Record review also showed R1 has a history of not wanting to shower and clean off after having an accident. Therefore, this allegation is deemed unsubstantiated. An exit interview was conducted, and a copy of this report was delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 03/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/17/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2