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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:06:29 PM

Document Has Been Signed on 10/16/2024 02:06 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: 3DATE:
10/16/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:15 AM
MET WITH:Henry ColemanTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
NARRATIVE
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On 10/15/2024 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct a Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. On January 17, 2023, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office and as a result of that NCC, the facility was placed on a two year compliance plan.

LPA arrived at 09:15 am and was greeted by staff member. LPA called and spoke to Administrator who stated that House Managers (HM) Henry Coleman would be able to meet with LPA. HM arrived shortly after, and LPA explained the purpose of the visit.

Staff member informed LPA that three (3) out of four (4) clients were currently in their day programs. One (1) client was observed in their room sleeping.

Today’s focus was Capacity Determination, Food Service, Health Related Services, Building and Grounds, Limitations on Capacity and Ambulatory Status, Personal Rights, and Client Records.

LPA conducted a physical plant tour and observed the facility maintains a comfortable temperature of 77°F.

Kitchen: The kitchen was clean and clear of clutter. LPA observed a two day supply of perishable and a seven day supply of non-perishable food at the facility all properly stored. LPA observed sharps or knives properly stored in a locked kitchen cabinet inaccessible to clients in care. Properly labeled medications were locked in one of the kitchen cabinets. The fire extinguisher is in the pantry and was observed fully charged with last service date 11/13/2023. Hot water temperature was measured at 118.1 degrees Fahrenheit.



Bedrooms: There are five (5) bedrooms, four (4) of which are designated for client use. All the bedrooms were properly furnished with appropriate bedding, linens and sufficient lighting.
Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2024
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: 10/16/2024
NARRATIVE
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Bathrooms: There are two (2) bathrooms, one (1) of which is designated for client use. Bathrooms were properly supplied with paper towels, hand soap and had functional fixtures. Extra toiletries and bathroom supplies are stored in the staff bathroom.

Common Areas: These included the living room and dining area. The common areas were properly furnished. Dining room and the living room are furnished with appropriate seating to comfortably seat the capacity of the facility.

Surrounding Grounds: Entry/exits were free of obstruction. There are no bodies of water on the premises. Garage is used for extra storage.



Laundry Room: The laundry room is in the hallway and is maintained locked. Detergents were observed to be locked in laundry room.

Medications: Medication and Medication Records were reviewed for proper documentation for four (4) of four (4) clients.

Client Records: Resident records were reviewed for proper documentation for four (4) out of four (4) clients.

Staff Records: Staff records were reviewed for proper documentation. One (1) staff out of eight (8) did not have a completed criminal record clearance. Staff member not cleared was staff member that greeted LPA and was providing care and supervision to one (1) client who was present in the home. LPA explained to HM that all staff need to be fingerprint cleared prior to beginning work. A civil penalty will be issued. Please see LIC809-D and LIC421BG.

LPA reviewed the LIC500 (Personnel Report) and found there to be sufficient staff for each shift. LPA also reviewed the staff training files. LPA verified that all staff have completed required training.

Civil penalty issued. Appeals rights discussed and provided. Exit Interview Conducted and a Copy of this report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/16/2024 02:06 PM - It Cannot Be Edited


Created By: Lorena Casillas On 10/16/2024 at 01:04 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: 10/16/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
10/17/2024
Section Cited
CCR
80019(e)(2)

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(e)All individuals subject to a criminal record review pursuant to …shall prior to working, residing or volunteering in a licensed facility: (2)Obtain a California clearance or a criminal record exemption as required by the Department.This requirement is not met as evidenced by:
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HM immediately asked staff #1 to leave and indicated that they will not be allowed to return until criminal record clearance is obtained. Once obtained HM will email proof to LPA.

Deficiency cleared during the visit.
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Based on observation and record review one (1) out of (8) staff has worked at the facility providing direct care to clients since 8/1/24 without a fully processed criminal record clearance. This poses an immediate risk to the health and safety of clients in care.
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A civil penalty for $500 was issued.

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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:Nichelle Gillyard
LICENSING EVALUATOR NAME:Lorena Casillas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024


LIC809 (FAS) - (06/04)
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