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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608821
Report Date: 11/08/2022
Date Signed: 11/08/2022 03:13:36 PM

Substantiated


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
06/29/2021 and conducted by Evaluator Wendell Smith
COMPLAINT CONTROL NUMBER: 31-AS-20210629084257
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: 4DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Staff do not provide resident with nutritious meals
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced subsequent visit to finish investigation into the allegation above. LPA met with facility staff and explained the reason for this visit.

Regarding the allegation above it is alleged facility did not provide clients with enough food. LPA conducted a previous visit on 9/10/22 where LPA conducted interviews with clients and staff regarding the allegation. Interviews revealed that clients were not provided with enough food and clients were limited on the food they were provided. Interviews also revealed that when clients asked for snacks they were denied. Based on the information obtained through interviews this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099 D. Appeal Rights explained. Exit Interview conducted.
Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
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 3
Control Number 31-AS-20210629084257
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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/08/2022
Section Cited
CCR
80076(a)(1)
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Food Service-In facilities providing meals to clients, the following shall apply:All food shall be safe and of the quality and in the quantity necessary to meet the needs of the clients.
This requirement was not met as evidenced by:
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Corrected before visit. LPA observed there to be a sufficient amount of food to meet the clients needs during the visit.
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Based on interviews conducted it was found that clients were not provided with enough food to meet their needs which posed a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 3