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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 12/18/2024
Date Signed: 12/18/2024 03:48:59 PM

Document Has Been Signed on 12/18/2024 03:48 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: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:
12/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:40 PM
MET WITH:Henry ColemanTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with House Manager, Henry Coleman for an unannounced one (1) year Required visit for this facility. On January 17, 2023, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office. As a result of that NCC, the facility was placed on a two-year compliance plan.

LPA arrived at 12:40 pm and was greeted by staff who then called Administrator Jessica Hernandez. LPA informed the Administrator of the purpose of the visit, Administrator stated that they would not be able to meet LPA and that they would assign House Manager (HM) Henry Coleman to sign the report. Two (2) clients were observed in the living room watching TV and/or socializing and two (2) clients were out in the community. HM arrived shortly after, and an entrance interview was conducted.

Infection control: LPA reviewed facility mitigation plan (approved on 03/20/21) to make sure licensee was following current infection control recommendations.

A tour of the physical plant was conducted with a staff member at 01:00 pm. The facility has five (5) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bathroom and one (1) bedroom are designated for office use only and the facility has awake staff at night. The facility is Fire Cleared for four (4) ambulatory clients.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 75°F. The smoke and carbon monoxide detectors were tested and observed to be operational at 01:10 pm.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/18/2024
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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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: WILLOUBEE RESIDENTIAL INC.
FACILITY NUMBER: 197608821
VISIT DATE: 12/18/2024
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Kitchen: LPA conducted a tour of the kitchen around 01:20 pm and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp object locked and inaccessible to clients in care. The fire extinguisher, located in the kitchen, was observed to be full and last serviced on 12/17/24. Medications are in a locked cabinet in the kitchen inaccessible to clients in care.

Client Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.

Bathrooms: At 01:30 pm LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested at 01:30 pm and measured within regulation at 112.2 degrees F.

Laundry: At 01:40 pm LPA observed chemicals/hazardous items in the locked laundry room.

Physical environment: LPA toured the outside area of the facility at 01:45 pm. LPA observed outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Garage: LPA observed the garage to be attached to the facility and currently being used as a lounge area and extra storage.

Administrative: LIC500, Bond Certificate, Administrator Certificate and client roster collected. Annual fees are current. Training documents were focused on Capacity Determination, Food Service, Health Related Services, Building and Grounds, Limitations on Capacity and Ambulatory Status, Personal Rights, and Client Records, LPA reviewed training documents.

Client and Staff Files: LPA conducted a file review of client and staff records at 02:15 pm.



Medications: At 03:00 pm LPA and HM reviewed medication and medication records.

Staff and Client Interviews: At 03:20 LPA interviewed staff.
No citations issued. Exit interview conducted. Copy of report provided to HM..
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 12/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2024
LIC809 (FAS) - (06/04)
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