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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 02/01/2024
Date Signed: 02/01/2024 12:17:47 PM

Document Has Been Signed on 02/01/2024 12:17 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 IIIFACILITY NUMBER:
197609859
ADMINISTRATOR:HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:3631 E GARNET LANETELEPHONE:
(661) 350-3495
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
02/01/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:05 AM
MET WITH:Jessica HernandezTIME COMPLETED:
12:32 PM
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On 02/01/2024 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 11:15 am LPA Casillas was granted entry by the Administrator. All four (4) clients were out in the community.

At 11:20 a.m., LPA and the Administrator took a tour of the physical plant.

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

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 11/13/2023. Hot water temperature was measured at 118.0 degrees Fahrenheit.



Bedrooms: There are four (4) bedrooms that are designated for client use. All the bedrooms were properly furnished with appropriate bedding, linens, a chair and sufficient lighting.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/01/2024
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 III
FACILITY NUMBER: 197609859
VISIT DATE: 02/01/2024
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Bathrooms: There are two (2) bathrooms designated for client use. Bathrooms were properly supplied with paper towels, hand soap and had functional fixtures. Extra toiletries and bathroom supplies are stored in a locked cabinet in the kitchen.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room and the living room are furnished with appropriate seating to comfortably seat the capacity of the facility. The facility maintains a comfortable temperature of 74°F.

Surrounding Grounds: Entry/exits were free of obstruction. The laundry room is located in the hallway and is maintained locked. The garage door is in the hallway. The garage is used for extra storage. The backyard has enough outside furniture for all clients in care. There is an umbrella for shade that was put away due to the weather.



Medications: Medication and Medication Records were reviewed for proper documentation for one (1) of four (4) clients.

Client Records: Client 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 and collected the staff training files. LPA verified that all staff have completed the 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: 02/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/01/2024
LIC809 (FAS) - (06/04)
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