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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 197609322
Report Date: 11/08/2022
Date Signed: 11/08/2022 12:08:25 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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 Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221018144110
FACILITY NAME:WILLOUBEE RESIDENTIAL IIFACILITY NUMBER:
197609322
ADMINISTRATOR:WILLOUGHBY, MARCUS AFACILITY TYPE:
735
ADDRESS:3123 EMERALD LNTELEPHONE:
(661) 992-7699
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 4DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
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Staff not providing adequate food service.
Facility operating out of ratio.
INVESTIGATION FINDINGS:
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Licensing Program Analysts (LPA) Evelin Rios, Wendell Smith, and Tihesha Smith made an unannounced complaint visit to finish the investigation on the allegations above. LPA met with staff #1 (S1) who granted access and the administrator met us shortly after and LPA explained the reason for this visit.
In regard to the allegations above:
Staff not providing adequate food service.
It is alleged that the facility has not had enough food in the home. On 10/21/2022 LPA conducted interviews with clients and staff. LPA also checked the food supply in the facility. During todays visit LPAs conducted interviews and staff and checked the food supply again. Information obtained through interviews and observation reveal that there have been instances when the facility has not had enough food for the clients. It was observed there was not a sufficient amount of snacks for clients and not enough perishable foods for clients. Based on the information obtained this allegation is deemed Substantiated at this time. Deficiency cited on LIC 9099D.

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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 5
Control Number 31-AS-20221018144110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL II
FACILITY NUMBER: 197609322
VISIT DATE: 11/08/2022
NARRATIVE
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Facility operating out of ratio.

It is alleged facility is transporting clients from other facilities to the home where only one staff member is working. On 10/21/2022 LPA conducted Interviews with clients and staff. During todays visit LPAs observed clients from different facilities. During the visit it was observed that the facility had clients from other facilities that did not reside in this facility. Interviews revealed that there were more than double the capacity of clients at this facility to which care and supervision was being provided for. Based on interviews conducted, observations made the allegation is deemed Substantiated. Deficiency cited on LIC 9099 D.

Civil penalty for 500 dollars issued for facility operating out of ratio.

Appeal Rights explained. Exit Interview conducted.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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 5
Control Number 31-AS-20221018144110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL II
FACILITY NUMBER: 197609322
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2022
Section Cited
CCR
80028(b)(6)
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80028(b)The number of persons for whom the facility is licensed to provide care and supervision shall be...(6)Number of available staff to meet the care and supervision needs of the clients.
This requirement is not met as evidence by:
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Administrator will submit a detailed plan as to what steps will be taken to ensure that their staffing ratios are met at all times by POC due date 11/09/2022.
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Based on LPA observation and various interviews conducted which revealed that facility does not have enough staff necessary to meet the clients needs which poses an immediate health and safety and personal rights risk to residents in care.
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Type A
11/08/2022
Section Cited
CCR
85076(d)(1)
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85076 (d)The licensee shall meet the following food supply and storage requirements:(1)Supplies of staple fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidence by:
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Administrator has already done the grocery shopping and has cleared this deficiency.

No follow up required.
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Based on LPA observation and various interviews conducted which revealed that facility did not have fresh perishable foods for a minimum of two days.
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

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

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 31-AS-20221018144110
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL II
FACILITY NUMBER: 197609322
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/08/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/09/2022
Section Cited
CCR
80010(a)
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Limitations on Capacity-A licensee shall not operate a facility beyond the conditions and limitations specified on the license.
This requirement was not met as evidenced by:
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Administrator shall submit detailed plan on how properly care for the correct amount of clients the facility is cleared to care for.
Immediate civil penalty of 500 dollars is issued.
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Based on observation and interviews it was found that the facility which is licensed to serve four clients has been providing care and supervision to more than eight clients at a time which poses a potential health and safety risk to clients in care.
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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.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

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

DATE: 11/08/2022
LIC9099 (FAS) - (06/04)
Page: 4 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 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 Evelin Rios
PUBLIC
COMPLAINT CONTROL NUMBER: 31-AS-20221018144110

FACILITY NAME:WILLOUBEE RESIDENTIAL IIFACILITY NUMBER:
197609322
ADMINISTRATOR:WILLOUGHBY, MARCUS AFACILITY TYPE:
735
ADDRESS:3123 EMERALD LNTELEPHONE:
(661) 992-7699
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY:4CENSUS: 4DATE:
11/08/2022
UNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:30 PM
ALLEGATION(S):
1
2
3
4
5
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9
Residents do not have access to toiletries.
INVESTIGATION FINDINGS:
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2
3
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5
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7
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12
13
Licensing Program Analysts (LPA) Evelin Rios, Wendell Smith, and Tihesha Smith made an unannounced complaint visit to finish the investigation on the allegation above. LPAs met with staff #1 (S1) and were granted access. The administrator met us shortly after and LPA explained the reason for this visit.

In regard to the allegation above:
Residents do not have access to toiletries.
It was alleged the toiletries are locked up so residents can’t get what they need when they need items (toilet paper, toothpaste etc. On 10/21/2022 LPA conducted interviews with clients and staff. LPA also checked the toiletries supply in the facility. Based on the information obtained this allegation is deemed Unsubstantiated at this time. No Deficiency cited. Exit Interview conducted. Copy of this report given.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
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: 5 of 5