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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:19:05 PM

Document Has Been Signed on 10/26/2023 04:19 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.ASC, 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: DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Jessica HernandezTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit and was greeted by the manager. The Administrator arrived at 12:45 pm. The facility is licensed as an adult residential facility to serve four ambulatory residents and staff confirmed there are four residents living in the facility.

LPA and the manager began the tour of the facility at 12:00 pm until 12;40 pm. LPA observed the following:

Living Room– LPA Spaeth observed the living room comfortable seating and a television.

Kitchen/Dining room - The dining room and kitchen are combined. LPA Spaeth observed a seven-day supply of non-perishable food and a two-day supply of perishable foods. The fire extinguisher is located in the kitchen. LPA observed the knives, first aid kit and residents' medications were locked in a kitchen cabinet. The cleaning solutions were locked in a cabinet underneath the sink. The dining area contained a dining room table and chairs The water temperature was tested at 12:40 pm and the temperature was 110.0 F.

Bathroom – LPA Spaeth observed the bathroom contained hand soap, paper towels, and a trash can.

Bedrooms – LPA Spaeth observed there are four client bedrooms in the facility. The bedrooms contained bed, linens, night stand, chair, chest of drawers and night lamp.

Staff Room – LPA observed the staff room was locked.

Laundry Room – LPA Spaeth observed the laundry room was locked and contained a washer and dryer along with the laundry detergent.

Garage - LPA observed the emergency water supply, PPE supplies and an additional refrigerator with additional food

Cont'd on 809-C

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/26/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL II
FACILITY NUMBER: 197609322
VISIT DATE: 10/26/2023
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Backyard – LPA Spaeth observed comfortable seating in a shaded area. The side gate leading from the backyard to the front yard was not locked.

Smoke/Carbon Monoxide Detectors – The smoke/carbon monoxide detectors were tested at 1:00 pm and are operational. .

LPA reviewed client's records at 1:00 pm until 1:20 pm. P&I funds were reviewed 1:20 pm until 1:35 pm. LPA reviewed medications at 1:35 untl 1:50 pm. LPA reviewed staff records at 1:50 pm until 2;15 pm.

There are no deficiencies at this time.



Exit interview conducted, and a copy of the signed report was given to caregiver.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
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