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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608821
Report Date: 12/28/2023
Date Signed: 12/28/2023 02:02:22 PM

Document Has Been Signed on 12/28/2023 02:02 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:MARCUS WILLOUGHBYFACILITY TYPE:
735
ADDRESS:3559 EMERALD LANETELEPHONE:
(661) 941-9051
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Jessica Hernandez, AdministratorTIME COMPLETED:
02:30 PM
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At 10:25 am. on 12/28/2023, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Staff, Martishia Douglas, who granted access to the facility. Administrator, Jessica Hernandez, arrived 11:10 am and LPA explained the reason for the visit. At 11:15 am, physical tour was conducted with the Administrator Jessica Hernandez and LPA observed the following:

The facility is a single-story building. The facility has five (5) bedrooms and two (2) bathrooms. One (1) bathroom and one (1) bedroom is designated for office use only and the facility has awake staff at night.

Kitchen: At 11:17 am LPA and Administrator toured the kitchen and LPA observed an adequate supply of perishable and non-perishable food. Surfaces were sanitary. LPA observed a complete first aid kit in a locked cabinet in the kitchen.. The house phone was located in the kitchen as well. Facility files and consumer medication were locked in the kitchen cabinet. Weekly menu were posted, at 11:20 am LPA observed a fully charged fire extinguisher in the kitchen pantry and was last serviced on 11/22/2023.

Living/dining: All indoor passageways were free from obstruction; with adequate lighting, walls, floors, ceilings, windows, screens and blinds were clean and in good repair. All areas were clean and appropriately furnished for client's comfort. At 11:25 am LPA measured the room temperature to be 74 degrees Fahrenheit. Activity schedule was observed and posted by the front door at the bulletin board.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
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
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: 12/28/2023
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Bedrooms: At 11:30 am LPA observed four (4) bedrooms designated for clients. All bedrooms are private. Room # one (1) is used for an office use only and LPA observed the office to be locked. All bedrooms for clients use contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility has two(2) bathrooms. Bathroom # one (1) is located in the office and only used by the staff. Bathroom # two (2) was located in the hall and shared by all clients. It contained liquid soap, paper towels, a handwashing instruction sign,a trash can with a lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 11:35 am LPA measured the water temperature in the bathroom to be 114.4 degrees Fahrenheit.

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


Laundry: Laundry room is located in the front hall. LPA observed chemicals/hazardous items was locked and contained a washer, dryer. Machines were in good condition. Detergent was locked in the laundry room.
Safety: All emergency exit paths were free from obstructions. There is only one exit gate and was unlocked with inward facing latches. Emergency Disaster Plan was posted at the front. Exit routes were clearly labeled.

Outdoor areas: LPA observed a covered patio with appropriate furniture, a basketball hoop in the front of the facility outside. All area were clean and free from debris.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: 12/28/2023
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Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:40 am, they were tested and observed to be operational. Carbon monoxide was located in the hall by the front door and was also tested and observed to be operational.

Administrative: Annual fee is current. LPA collected Certificate of Liability Insurance, and LIC.500.

Between 11:45 am to 1:50 pm, LPA reviewed records of four (4) clients and three (3) staff. Client and staff records appeared to be complete and updated.

During today's inspection, the facility is in compliance with Title 22 regulations. No citation issued.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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