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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 07/08/2024
Date Signed: 07/08/2024 02:36:50 PM

Document Has Been Signed on 07/08/2024 02:36 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:
07/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:15 AM
MET WITH:Jessica HernandezTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with Administrator Jessica Hernandez for an unannounced one (1) year Required visit for this facility. 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. LPA arrived at 11:15 am and was greeted by Administrator Jessica Hernandez. LPA informed the Administrator of the purpose of the visit.

A tour of the physical plant was conducted with Administrator at 11:30 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) residents. The facility is Fire Cleared for four (4) ambulatory.

Infection control: LPA reviewed facility mitigation plan (approved on 06/29/2022) to make sure licensee was following current infection control recommendations.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a temperature of 73°F. The smoke and carbon monoxide detectors were tested and observed to be operational at 11:45 am.

Kitchen: At 12:00 pm LPA observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to residents in care. The fire extinguisher, located in the kitchen, was observed to be full and last serviced on 11/13/23. Medications was located in a cabinet in the kitchen and were observed to be locked and inaccessible to residents in care.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 II
FACILITY NUMBER: 197609322
VISIT DATE: 07/08/2024
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Resident Rooms: LPA observed rooms to have the appropriate bedding. There is a nightstand, chair and sufficient lighting for each client.

Bathrooms: At 12:10 pm LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested at 12:10 pm and measured within regulation at 119.7 degrees F.

Laundry: At 12:15 pm LPA observed chemicals/hazardous items in the locked laundry room.

Physical environment: LPA toured the outside area of the facility at 12:20 am. LPA observed outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Garage: LPA observed the garage to be attached to the facility and currently being used as extra storage with an extra fridge.

Administrative: LIC500, Bond, Administrator certificate and client roster collected. Annual fees are current.

Resident Files: LPA conducted a file review of resident records at 12:30 pm.

Staff Files: LPA conducted a file review of staff records at 01:00 pm.

Medications: At 01:30 pm LPA and Administrator reviewed medication and medication records.

Staff Interviews: At 02:00 pm LPA interviewed staff.

Client Interviews: There were no clients in the home to interview.

There are no deficiencies to report and no citations to be issued. Exit interviewed conducted and a copy of the report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
LIC809 (FAS) - (06/04)
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