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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 01/04/2024
Date Signed: 01/04/2024 11:43:33 AM

Document Has Been Signed on 01/04/2024 11:43 AM - 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:WILLOUGHBY, MARCUS AFACILITY TYPE:
735
ADDRESS:3123 EMERALD LNTELEPHONE:
(661) 992-7699
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
01/04/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:00 PM
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On 01/04/2024 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct 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 9:00 am LPA Casillas was greeted by staff member Martishia Douglas who allowed entry and proceeded to call Administrator Jessica Hernandez. One (1) client was having pain and behavior concerns and staff was attending to that client. Administrator arrived at 10:10 am.

At approximately 10:00 a.m., LPA and staff member took a tour of the physical plant. Two (2) residents were attending day programs and two (2) residents were home. During the visit one (1) resident was taken to her doctors office for treatment of pain and the other resident went out to the community.

Today’s focus was infection control, administrator certification, training for staff, and sufficient staffing for supervision.

LPA conducted a physical plant tour and observed the facility maintains a comfortable temperature of 75°F.

Kitchen: 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 05/13/2023. Hot water temperature was measured at 115.9 degrees Fahrenheit.



Continued on 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/04/2024
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: 01/04/2024
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Bedrooms: There are five (5) bedrooms, four (4) of which are designated for client use. All the bedrooms were properly furnished with appropriate bedding, 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. 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 seat the capacity of the facility.

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.

LPA reviewed the LIC500 (Personnel Report) and found there to be sufficient staff for each shift. LPA also reviewed the staff training files. LPA verified that all staff have completed required training.

No deficiencies observed during today's visit. Exit Interview Conducted and a Copy of this report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2024
LIC809 (FAS) - (06/04)
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