197609859-2-8-2024-31-AS-NMAN-D8Z4WT-20240910192827

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 197609859
Report Date: 02/08/2024
Date Signed: 02/08/2024 04:48:55 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

This is an official report of an unannounced visit/investigation of a complaint received in our office on
09/06/2023 and conducted by Evaluator Tihesha Smith

COMPLAINT CONTROL NUMBER: 31-AS-20230906110330

FACILITY NAME:	WILLOUBEE RESIDENTIAL III		FACILITY NUMBER:	197609859
ADMINISTRATOR:	HERNANDEZ, JESSICA I		FACILITY TYPE:	735
ADDRESS:	3631 E GARNET LANE		TELEPHONE:	(661) 350-3495
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93535
CAPACITY:	4	CENSUS: 4	DATE:	02/08/2024
		UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Jessica Hernandez		TIME COMPLETED:	04:55 PM

ALLEGATION(S):

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Staff does not provide adequate food service to residents
Staff do not treat residents with dignity and respect

INVESTIGATION FINDINGS:

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Licensing Program Analyst (LPA) Tihesha Smith made an unannounced subsequent complaint visit to this facility at approximately 11:15 am. LPA Smith met with staff Chanel and disclosed the purpose of the visit. The administrator was contacted and arrived later.

During initial visit, on 09/06/23, LPA Antonia Alvizar-Ettima conducted tour of physical plant and requested documents relevant to the investigation.

Staff does not provide adequate food service to residents

It was alleged that staff does not provide adequate food service to residents. During today's visit, LPA reviewed facility files and requested copies, interviewed staff and residents, and conducted a physical plant inspection from 11:20 am -4:15 pm. LPA unable to interview Resident #1(R1) as no longer resides at the facility.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

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Control Number 31-AS-20230906110330

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOUBEE RESIDENTIAL III	FACILITY NUMBER: 197609859
	VISIT DATE: 02/08/2024

NARRATIVE

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(Cont from 9099)

Three (3) of three (3) staff reveal facility provides cooked meals which include: breakfast, lunch, and dinner. Interview with the administrator revealed groceries provided every two weeks for the home and residents are asked if they require any items when shopping list created. Administrator also revealed residents may refuse meals and opt to eat snack items instead of prepared meals. During the kitchen inspection, LPA checked the refrigerator, freezer, pantry and countertops and observed non-perishable and perishables food for the residents; observed the daily menu and observed more groceries delivered during visit. Interview with three (3) of three four (4) residents revealed food is ok. Two (2) of four (4) residents reveal they are picky about food and will eat a snack if they don’t want the prepared meal.

Based on interviews, posted menu and physical plant inspection there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

Staff do not treat residents with dignity and respect.

Interview with three (3) out of four (4) residents revealed that staff always treats them with dignity and respect and they do not have any concerns regarding this allegation. R4 and R5 reveal staff are nice and help when they need it. R4 also revealed staff are like family and they treat us like family. Interview with Administrator and two (3) staff members reveal was staff always treat residents with dignity and respect. One (1) of three (3) staff reveal residents are treated like family and they always respect the residents.

Based on information obtained through interviews there is not enough sufficient evidence to support the allegation. Therefore, the allegation is Unsubstantiated at this time.

No Deficiencies noted at time of visit.

Exit interview conducted/copy of report given

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2024

LIC9099 (FAS) - (06/04)

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