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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 01/13/2023
Date Signed: 01/13/2023 04:27:42 PM

Document Has Been Signed on 01/13/2023 04:27 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
N LA & CEN COA AC/SC, 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:
01/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
03:21 PM
MET WITH:Jessica HernandezTIME COMPLETED:
04:30 PM
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On 01/13/2023 at 3:21 p.m., Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above for a case management visit regarding Community Care Licensing (CCL) concerns of care and supervision and staff not providing adequate food to clients in care. Upon arrival LPA was granted access to the facility by staff #1 (S1). There were three (3) staff, and two (2) clients present at this time. Staff #2 (S2) let administrator know LPA was at facility. S2 stated administrator would meet us shortly.

From 3:21 p.m. to 3:44 p.m. LPA began a physical plant tour of the facility which consisted of the living room, kitchen, client rooms and bathrooms. At approximately 3:50 p.m. two (2) more clients arrived from day program. At 4:03 p.m. LPA observed Staff #3 (S3) distribute medications to clients in care. LPA did not observe any issues on todays visit. From 4:05 p.m. to 04:14 p.m. LPA conducted interviews with the other two (2) clients who had arrived from day program. At 4:20 p.m. LPA requested IPP and physicians report's from administrator Jessica Hernandez for the four (4) clients in care via email by next day.

No deficiencies cited. Exit interview conducted, and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
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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