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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 06/05/2024
Date Signed: 06/05/2024 02:08:05 PM

Document Has Been Signed on 06/05/2024 02:08 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 IIFACILITY NUMBER:
197609322
ADMINISTRATOR/
DIRECTOR:		WILLOUGHBY, MARCUS AFACILITY TYPE:
735
ADDRESS:3123 EMERALD LNTELEPHONE:
(661) 992-7699
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
06/05/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Jessica HernandezTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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On 06/05/2024 LPA Casillas arrived at facility above to conduct an initial 10-day complaint investigation for complaint 31-AS-20240530152840. This Case Management is not related to the original complaint visit. During record reviews LPA observed that a special incident report (SIR) was not reported or sent into Community Care Licensing for an incident that occurred on 5/23/24.

During LPA’s visit, LPA observed there was an SIR missing for 05/23/24 where a client requested medical intervention. LPA interviewed Administrator and Administrator admitted to not reporting incident because they thought that the day program was responsible for reporting since the incident happened at day program. LPA explained that anytime an incident occurs it needs to be reported to CCL within seven (7) days as the facility is responsible for the client and their wellbeing.

Administrator agreed to send CCL SIR to report the incident and will provide Vendor Approved training for all staff on reporting requirements by POC due date.

Citation issued. Appeal rights discussed and provided. Exit interview conducted and a copy of this report was given to Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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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Document Has Been Signed on 06/05/2024 02:08 PM - It Cannot Be Edited


Created By: Lorena Casillas On 06/05/2024 at 12:11 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 II
FACILITY NUMBER: 197609322

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/05/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/14/2024
Section Cited
CCR
80061(b)

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(b)Upon the occurrence…a report shall be made to the licensing agency...In addition, a written report …shall be submitted to the licensing agency within seven days following the occurrence.. This requirement is not met as evidenced by:
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Administrator agreed to send CCL the SIR to report the incident and will provide Vendor Approved training for all staff on reporting requirements by POC due date.
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Based on record reviews, interviews and observations Administrator failed to report an incident to CCL. This poses a Health, Safety, and Personal risk to residents 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.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Lorena Casillas
LICENSING EVALUATOR SIGNATURE:
DATE: 06/05/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/05/2024


LIC809 (FAS) - (06/04)
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