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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197608821
Report Date: 11/08/2022
Date Signed: 11/08/2022 03:20:04 PM

Unsubstantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/18/2022 and conducted by Evaluator Tihesha Smith
COMPLAINT CONTROL NUMBER: 31-AS-20221018143535
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: 2DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
10:40 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff not providing adequate food service.
Residents do not have access to toiletries.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPAs) Tihesha Smith, Wendell Smith, and Evelin Rios conducted a subsequent complaint visit to deliver findings. LPA met with Director Jessica Hernandez and disclosed the purpose of the visit.
During initial visit on 10/20/22, LPA Smith conducted a physical plant tour to ensure there were no immediate health and safety issues. LPA did not observe any health and safety issues. Regarding the allegations above LPA conducted interviews with the Director and House Manager from 11:35– 12:45 PM. LPA obtained copies of documents relevant to the investigation from 12:30 PM-1 :20 PM.
Staff is not providing adequate food service
It was alleged that the staff are not providing adequate food services. LPA Smith interview with Resident 1 (R1) revealed that enjoys meals and always has food items available. LPA interview with staff revealed that the facility does shopping via Instacart either weekly or biweekly. LPA observed an adequate supply perishable and non-perishable food for the residents in at time of visit. The facility also has a menu posted in the
(Cont to 9099C)
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 2
Control Number 31-AS-20221018143535
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL INC.
FACILITY NUMBER: 197608821
VISIT DATE: 11/08/2022
NARRATIVE
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(Cont from 9099)

kitchen and on the refrigerator with various meal offerings including but not limited to:

Breakfast: Blueberry oatmeal, toast, or pancakes with bacon and eggs

Lunch: Beef and bean burrito, soup, or Hot Dogs

Dinner: Steak with Mash potatoes, corn to baked fish or pork chops with rice and beans.

Staff also revealed (R1) on a vegan diet, and he writes out his own menu which is posted next to facility menu and ensures those items are made available.

Based on information gathered during previous licensing visit and interviews there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.


Residents do not have access to toiletries

It was alleged that residents do not have access to toiletries such as toilet paper and toothpaste. During tour of facility on 10/18/22, LPA Smith observed the facility had supply of toiletries items in kitchen pantry including a personal supply of deodorant, toothpaste, and toilet paper toilet observed in unlocked drawer and cabinet in bathroom used by residents. LPA also observed hygiene products in R1 room on dresser. Interview with staff revealed that residents are routinely asked if any hygiene products or other items need to be replenished. R1 also revealed they have toiletries in room on dresser and additional toiletries for all residents are in the bathroom.

Based on information gathered during previous licensing visit and interviews there is no relevant information to support the allegation. Therefore, the allegation is UNSUBSTANTIATED at this time.


SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 2 of 2