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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:05:21 PM

Document Has Been Signed on 01/13/2023 03:05 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:MARCUS WILLOUGHBYFACILITY TYPE:
735
ADDRESS:3559 EMERALD LANETELEPHONE:
(661) 941-9051
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
01/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica HernandezTIME COMPLETED:
03:15 PM
NARRATIVE
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On 01/13/2023 at 9:00 a.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above for a case management visit regarding Community Care Licensing (CCL) concerns of care and supervision and staff not providing adequate food to clients in care. Upon arrival LPA granted access to the facility by staff #1 (S1). There were only one (1) staff, and two (2) clients (client #1(C1) and client #2 (C2)) present at this time. LPA spoke with the Administrator Jessica Hernandez over the phone and explained the reason for the visit. Administrator stated she was on her way to another facility and if she could not make it to this facility, she would designate S2 to sign today’s report.

From 9:00 a.m. to 9:15 a.m. LPA began a physical plant tour of the facility. From 9:15 a.m. to 9:42 a.m. LPA conducted interviews with two (2) out of four (4) clients, staff at the facility and administrator over the phone. LPA requested physician’s reports for two (2) out of the four (4) clients in care. Administrator stated facility had requested from C1 they have a medical assessment and documents with them before arrival to the facility. According to administrator when they picked up C1 they did not have the documents with them and they have asked C1 repeatedly to get it done. At approximately 10:00 a.m. staff #2 (S2) and another client #3 (C3) arrived at the facility to relieve S1. C3 left shortly after for work. From 9:42 a.m. to 10:00 a.m. LPA completed a physical plant tour of the facility. LPA observed food designated for one client’s special dietary needs labeled with client’s name. LPA observed a weekly menu schedule from 01/9/2023 to 01/15/2023 on the fridge the lunch menu stated on 01/14/23 lunch will be a snack tray of assorted vegetables meant for three (3) out of the four (4) clients to share. LPA asked S2 if this is all they have for lunch that day. S2 stated they may have some chips with it. From 10:00 to 10:45 a.m. LPA reviewed facility records and client files. The Administrator arrived at 2:00 p.m. LPA reviewed requested physician's reports and LPA did not accept two (2) out of two (2) physician's reports due to missing information.
Deficiencies cited refer to LIC 809D. Exit interview conducted, appeal rights provided and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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 3
Document Has Been Signed on 01/13/2023 03:05 PM - It Cannot Be Edited


Created By: Evelin Rios On 01/13/2023 at 12:19 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL INC.
FACILITY NUMBER: 197608821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
80070(b)(8)

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(b) Each record must contain information including, but not limited to, the following:(8) Medical assessment, including ambulatory status, as specified in Section 80069.
This requirement is not met as evidenced by:
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Licensee will review client records and identify records that are missing according to sections 80070 and 85070 and submit to LPA Physician's Reports and Appraisal/Needs and Services plan for cleints identified to not have documents on file by POC date 1/20/2023.
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Based on record review and interviews, the Licensee did not ensure two (2) out of four (4) clients in care had physician's reports/medical assessments on file before admitting them to the facility which poses a potential health, safety or personal rights risk to persons in care.
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HSC

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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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 01/13/2023 03:05 PM - It Cannot Be Edited


Created By: Evelin Rios On 01/13/2023 at 12:35 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL INC.
FACILITY NUMBER: 197608821

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/20/2023
Section Cited
CCR
80076(a)(1)

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80076(a)(1) Food Services- In facilities providing meals to clients, the following shall apply: (1)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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Licensee agrees to plan meals following requirements necessary within section 80076(a)(1). Copies of weekly meals scheduled for the month of January and February 2023 shall be submitted to LPA by the POC due date.
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Based on observation and interviews, the licensee did not ensure a lunch meal (snack tray of assorted vegetables) met the quantity necessary to meet the needs of three (3) out of the four (4) clients in care. This poses an immediate health and safety or personal rights 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.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Evelin Rios
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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