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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609322
Report Date: 10/29/2024
Date Signed: 10/29/2024 01:03:49 PM

Document Has Been Signed on 10/29/2024 01:03 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:
10/29/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Rashayla HayesTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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On 10/29/2024 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct an unannounced Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. On January 17, 2023, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office and as a result of that NCC, the facility was placed on a two year compliance plan.

LPA arrived at 09:30 am and was greeted by staff member. Staff member called and spoke to Administrator who stated that House Manager (HM) Rashayla Hayes would be able to meet with LPA. HM arrived shortly after, and LPA explained the purpose of the visit.

Staff member informed LPA that three (3) out of four (4) clients were currently in their day programs. One (1) client was observed in their room sleeping. Throughout the visit the client woke up and went out to the community.

Today’s focus was Capacity Determination, Food Service, Health Related Services, Building and Grounds, Limitations on Capacity and Ambulatory Status, Personal Rights, and Client Records.

LPA conducted a physical plant tour and observed the facility maintains a comfortable temperature of 73°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 all 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 and was observed fully charged with last service date 11/13/2023. Hot water temperature was measured at 110.3 degrees Fahrenheit.



Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL II
FACILITY NUMBER: 197609322
VISIT DATE: 10/29/2024
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Bedrooms: There are five (5) bedrooms, four (4) of which are designated for client use. One (1) bedroom is used as an office. 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 client use. Bathroom was properly supplied with paper towels, hand soap and had functional fixtures. Extra toiletries and bathroom supplies are stored in a kitchen cabinet.

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. There are no bodies of water on the premises. Garage is used for extra storage.

Laundry Room: The laundry room is off to the side of the kitchen and is maintained locked. Detergents were observed to be locked in laundry room.

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

Client Records: Resident records were reviewed for proper documentation for four (4) out of four (4) clients.

Staff Records: Staff records were reviewed for proper documentation.

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 citations issued. Exit Interview Conducted and a Copy of this report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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