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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 06/14/2022
Date Signed: 06/14/2022 02:38:45 PM

Document Has Been Signed on 06/14/2022 02:38 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
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:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:35 PM
MET WITH:Jessica Hernandez, AdministratorTIME COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Shira Stamps arrived at the facility for an unannounced one (1) year Required visit. LPA arrived at 1:35 pm. LPA was greeted by caregiver Chanel, and the Administrator and the house manager were contacted. The house manager arrived at 1:50 pm. LPA informed the house manager of the purpose of the visit. Clients were observed doing karaoke in the living room.

A tour of the physical plant was conducted with the house manager, Rashalya at 1:50 pm. The Administrator arrived later at 2:05pm. The facility has five (5) bedrooms and two (2) bathrooms currently occupying four (4) clients. One (1) bedroom and one (1) bathroom is designated for staff use only. The facility is Fire Cleared for four (4) ambulatory.

Infection control: No mitigation plan was found on file for this facility. The Licensee has approved mitigation plans for their other three facilities. The Administrator stated she will send LPA the mitigation plan. LPA observed that the facility was following current infection control recommendations. Upon arrival LPA was screened by the caregiver and asked all infection control questions. LPA was asked to sign-in and sanitize hands.

Food Inspection
LPA conducted a tour of the kitchen around 1:54 pm 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 care clean and inaccessible to pests. LPA observed all knives and sharp object being locked and inaccessible to clients in care. The medication cabinet was also observed to be locked.

Laundry
At 1:55 pm, LPA observed chemicals/hazardous items in a locked cabinet in the laundry room.
CONTINUED...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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 2
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 II
FACILITY NUMBER: 197609322
VISIT DATE: 06/14/2022
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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 70°F. The smoke detectors dual carbon monoxide detectors were tested and observed to be operational at 2:08 pm. There one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced 8/13/21.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client.

Bathrooms
LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested at 2:00 pm and measured within regulation at 117.3 degrees F.

Physical environment
LPA toured the outside area of the facility at 2:06 pm. LPA observed a covered shaded area for clients. No bodies of water on the premises.

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: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2