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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 07/21/2023
Date Signed: 07/21/2023 12:02:38 PM

Document Has Been Signed on 07/21/2023 12:02 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
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:
07/21/2023
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:00 PM
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On 07/21/2023 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility above to conducted a Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. LPA met with Administrator Jessica Hernandez and explained the reason for the visit. On January 17, 2023, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office. As a result of that NCC, the facility was placed on a two year compliance plan.

At approximately 11:00 a.m., LPA and administrator took a tour of the physical plant. The smoke/carbon detectors are hardwired and interconnected and observed to be functioning properly.

Kitchen: LPA observed staff #1 (S1) working on laundry. The kitchen was clean and clear of clutter. LPA observed a two day supply of perishable and a seven day supply of non-perishable food at the facility; properly stored. LPA observed sharps or knives properly stored in a locked kitchen cabinet inaccessible to clients in care. Properly labeled medications were locked in one of the kitchen cabinets. The fire extinguisher is in the kitchen, was observed fully charged with last service date 10/19/2022.

Bedrooms: There are five (5) bedrooms four (4) of which are designated for client use. All the bedrooms were properly furnished with appropriate beddings, linens and sufficient lighting.

Bathrooms: There are two (2) bathrooms one (1) of which is designated for resident use. Bathrooms were properly supplied with paper towels, hand soap and had functional fixtures. Hot water temperature was measured at 117.6 degrees Fahrenheit. Extra toiletries and bathroom supplies are stored in the staff bathroom.

Common Areas: These included the living room and dining area. The common areas were properly furnished. Dining room and the living room are furnished with appropriate seating to comfortably sit the capacity of the facility. (LIC809 Continued on next page)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/21/2023
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: 07/21/2023
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Surrounding Grounds: Entry/exits were free of obstruction. The laundry room is located by the kitchen maintained locked. Laundry room leads to the garage where a second refrigerator and extra cleaning supplies are stored. LPA observed more frozen food in the garage refrigerator.

Medications: Medication and Medication Records were reviewed for proper documentation for one (1) of four (4) clients.

Client Records: Resident records were reviewed for proper documentation for one (1) of four (4) client records.

According to Administrator, annual staff training has been conducted for topics covered in the NCC.

No deficiencies observed during today's visit. Exit Interview Conducted and a Copy of this report was issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 07/21/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2023
LIC809 (FAS) - (06/04)
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