197608821-2-21-2026-31-AS-LCAS-DRJ26G-20260221160707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 02/21/2026
Date Signed: 02/21/2026 04:08:31 PM

Document Has Been Signed on 02/21/2026 04:08 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 WILLOUGHBY		FACILITY TYPE:	735
ADDRESS:	3559 EMERALD LANE		TELEPHONE:	(661) 941-9051
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY: 4		CENSUS: 3	DATE:	02/21/2026
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:45 AM
MET WITH:	Henry		TIME VISIT/ INSPECTION COMPLETED:	04:10 PM

NARRATIVE

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On 02/21/2026 at 10:45 am Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility for an unannounced one (1) year Required visit. LPA was greeted and granted access by staff. LPA met with House Manager (HM) Henry Coleman, as Administrator Jessica Hernandez, was not able to meet with LPA. Administrator designated HM to assist LPA and sign the report. LPA explained the reason for the visit and an entrance interview was conducted.

Infection Control and Emergency Preparedness Plan: LPA reviewed facility Infection Control Plan and Emergency Preparedness Plan to make sure protocols are being reviewed and/or updated. Plans were discussed and updated.

A tour of the physical plant was conducted with HM at 12:00 pm. The facility has five (5) bedrooms and two (2) bathrooms currently occupying three (3) clients. One (1) bedroom and one (1) bathroom are designated for staff. The facility is Fire Cleared for four (4) ambulatory clients. All the clients were home resting and watching TV in their rooms.

Kitchen: At 12:30 pm LPA 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 objects being double locked and inaccessible to clients in care. LPA also observed all chemicals/hazardous items locked and inaccessible. The medication cabinet was observed to be locked.

Continued on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: 02/21/2026

NARRATIVE

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Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke detector and dual carbon monoxide detectors were tested and observed to be operational. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full but last serviced on 12/02/2024. HM will make an appointment to have the fire extinguisher re-serviced as soon as possible and will send LPA email confirmation.

Bedrooms: There are four (4) client bedrooms for single use. LPA observed bedrooms to be properly furnished with a bed, linens, nightstand, chair, chest of drawers, closet, and adequate lighting. One (1) bedroom is used as a staff office.

Bathrooms: At 01:00 pm LPA observed bathrooms to have the appropriate wash your hands signs posted. Hot water was tested and measured within regulation at 110.3˚ F.

Laundry: LPA observed chemicals/hazardous items located in the locked laundry room.

Physical environment: LPA toured the outside area of the facility at 01:30 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Garage: LPA observed the garage to be attached to the facility and currently being used for storage and emergency food and water supply.

Administrative: Annual Fee is current. LPA collected LIC500, Bond, Client Roster, and Administrator Certificate.

Staff/Client Interviews: Throughout visit LPA conducted interviews.

Staff/Client Records: At 03:00 pm LPA conducted file reviews. During staff file reviews it was discovered that one (1) staff member received disciplinary action on 5/21/2025 that was also noted by North Los Angeles Regional Center (NLARC) who issued a Corrective Action Plan (CAP). LPA looked through SIR’s submitted to Community Care Licensing (CCL) and could not locate any special incident reports submitted for this occurrence. A citation will be issued for failure to report. LPA explained to HM that per regulations “Any unusual incident or client absence which threatens the physical or emotional health or safety of any client” needs to be reported to CCL within the time frame indicated in the regulations.

Citation issued. Exit interview conducted. Copy of report provided to HM.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Lorena Casillas
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 02/21/2026

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/21/2026 04:08 PM - It Cannot Be Edited

Created By: Lorena Casillas On 02/21/2026 at 01:55 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: 02/21/2026

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80061(b)(1)(E)

80061 Reporting Requirements (b)Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during its normal business hours. (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in that the facility failed to report a medication error on 05/04/25 and 05/11/25 for which a CAP was issued by NLARC, which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/28/2026
	Plan of Correction
1 2 3 4	HM discussed and agreed to in service training for all staff and agreed to submitting a written statement on how this will be avoided in the future via email by POC due date to LPA.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Nichelle Gillyard
NAME OF LICENSING PROGRAM MANAGER:

	Lorena Casillas
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 02/21/2026

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2026

LIC809 (FAS) - (06/04)

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