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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 09/09/2024
Date Signed: 09/09/2024 01:23:58 PM

Document Has Been Signed on 09/09/2024 01:23 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/
DIRECTOR:		HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:3631 E GARNET LANETELEPHONE:
(661) 350-3495
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 4DATE:
09/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Rashayla HayesTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Lorena Casillas met with House Manager Rashayla Hayes for an unannounced one (1) year Required visit for this facility. Facility is currently on a non-compliance plan.

LPA arrived at 10:00 am and was greeted by staff. LPA explained the reason for the visit and House Manager (HM) Rashayla Hayes was called. Administrator would not be able to attend, and HM was assigned by Administrator as designee to sign the report. HM arrived shortly after. A tour of the physical plant was conducted with HM at 11:00 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) clients. The facility is Fire Cleared for four (4) ambulatory.

Infection control: LPA reviewed facility mitigation plan (approved on 03/20/21) to make sure licensee was following current infection control recommendations.

Kitchen: LPA conducted tour at the kitchen at 11:00 am and observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. During the visit, facility had their weekly Monday food and supply delivery. LPA observed staff and clients cohesively putting goods away. LPA observed all knives and sharp objects being double locked and inaccessible to clients in care. LPA also observed all chemicals/hazardous items locked and inaccessible. The medication cabinet was observed to be locked.

Living and dining: LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 77°F. The smoke detector and dual carbon monoxide detectors were tested and observed to be operational at 11:15 am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full but last serviced on 11/13/2023.

Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2024
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: 09/09/2024
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Bedrooms: LPA observed rooms to have the appropriate bedding. There is a nightstand and sufficient lighting for each client.

Bathrooms: At 11:20 am LPA observed all bathrooms to have the appropriate wash your hands signs posted. Hot water was tested and measured within regulation at 110.8 degrees F.

Laundry: LPA observed chemicals/hazardous items located in the locked laundry room.

Physical environment: LPA toured the outside area of the facility at 11:25 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

Garage: LPA observed the garage to be attached to the facility and currently being used for storage and emergency food and water supply.

Administrative: Annual Fee is current. LPA collected LIC500, Liability and Bond Certificates and Client Roster.

Staff/Client Interviews: At 10:00 am LPA conducted interviews.

Staff/Client Records: At 11:30 am LPA conducted file reviews. LPA reviewed training hours for staff to meet noncompliance requirements, all hours are met.

Medication: At 01:00 pm LPA and HM reviewed medication and medication logs.

No citations issued. Exit interview conducted. Copy of report provided to Administrator and HM via email.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 09/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2024
LIC809 (FAS) - (06/04)
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