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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 07/22/2024
Date Signed: 07/22/2024 04:24:57 PM

Document Has Been Signed on 07/22/2024 04:24 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WILLOUBEE RESIDENTIAL INC.FACILITY NUMBER:
197608821
ADMINISTRATOR/
DIRECTOR:		MARCUS WILLOUGHBYFACILITY TYPE:
735
ADDRESS:3559 EMERALD LANETELEPHONE:
(661) 941-9051
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
07/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:24 PM
MET WITH:Henry Coleman (House Manager)TIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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On 07/22/2024 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above to conduct a Case Management visit in conjunction to complaint control number 31-AS-20210629084257. LPA met with Henry Coleman, the house manager. Assistant Administrator Jessica Hernandez was contacted by phone and LPA explained the reason for the visit. LPA is gathering copies for clients' cash resources, receipts and record of client's safeguarded cash resources (LIC405). Henry Coleman was designated to sign todays report.

LPA informed assistant administrator, that archived financial records for clients may be requested by LPA.

At 3:27 p.m. LPA obtained copies of two (2) out of four (4) clients' cash resources, record of client's safeguarded cash resources (LIC405) and receipts. Facility is only responsible for safeguarding two (2) of four (4) clients' cash.

Client #1 (C1) does not have receipts as they receive the whole amount of the personal and incidental (P&I) cash when deposited.

LPA interviewed Client #2 (C2) from 4:00 p.m. to 4:20 p.m.

No citations issued. Exit interview conducted. Copy of this report signed and provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 07/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/22/2024
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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