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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 12/30/2021
Date Signed: 12/30/2021 10:50:17 AM

Document Has Been Signed on 12/30/2021 10:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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
ADMINISTRATOR:MARCUS WILLOUGHBYFACILITY TYPE:
735
ADDRESS:3559 EMERALD LANETELEPHONE:
(661) 941-9051
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
12/30/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica Hernandez, AdministratorTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Shira Stamps met with Administrator Jessica Hernandez for an unannounced one (1) year Required visit for this facility.

LPA arrived at 10:00 am and was greeted by Administrator Jessica Hernandez. Eight (8) residents were observed in the living room watching TV and/or socializing at the dining room table. The rest of the residents were observed to be in their rooms watching TV and/or resting. LPA informed the Administrator of the purpose of the visit.

Infection control: LPA reviewed facility mitigation plan (approved on 03/20/21) to make sure licensee was following current infection control recommendations. Upon arrival LPA was screened by the Administrator, and asked all infection control questions. LPA was asked to sign-in.

A tour of the physical plant was conducted with Administrator at 10:01am. The facility has five (5) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bathroom and one (1) bedroom is designated for office use only and the facility has awake staff at night. The facility is Fire Cleared for four (4) ambulatory.

Resident Rooms
LPA observed each room to have the appropriate bedding, sheets, pillowcase, mattress pad, and blankets; which are in good condition. There is a nightstand and sufficient lighting for each resident.

Bathrooms
At 10:05 am LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 10:18am and measured within regulation at 111.4 degrees F. Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL INC.
FACILITY NUMBER: 197608821
VISIT DATE: 12/30/2021
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Laundry
LPA observed chemicals/hazardous items in the locked laundry room.

Food Inspection
LPA conducted a tour of the kitchen around 10:00 am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are care clean and inaccessible to pests. LPA observed all knives and sharp object locked and inaccessible to residents in care.

Physical environment
LPA toured the outside area of the facility at 10:12am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

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 77°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 10:20am. The fire extinguisher, located in the kitchen, was observed to be full and last serviced on 08/13/21. Medications was located in a cabinet in the kitchen and at 10:05 am; was observed to be locked and inaccessible to residents in care.

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

Administrative: Annual fee is current.

An exit interview was conducted, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 12/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/30/2021
LIC809 (FAS) - (06/04)
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