197609859-2-24-2025-31-AS-LCAS-DE7TVY-20250224140445

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 02/24/2025
Date Signed: 02/24/2025 02:04:57 PM

Document Has Been Signed on 02/24/2025 02:04 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 III		FACILITY NUMBER:	197609859
ADMINISTRATOR/ DIRECTOR:	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: 3	DATE:	02/24/2025
TYPE OF VISIT:	Case Management - Legal/Non-compliance	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Jessica Hernandez		TIME VISIT/ INSPECTION COMPLETED:	02:05 PM

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On 02/24/2025 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 10:00 am and was greeted by Administrator Jessica Hernandez. LPA explained the purpose of the visit and conducted an entrance interview.

Administrator informed LPA that two (2) out of three (3) clients were currently in their day programs. One (1) client was present.

Today’s focus was Care and Supervision, Food Service, Medication Documentation, Building and Grounds, Limitations on Capacity and Ambulatory Status, and Personal Rights.

LPA conducted a physical plant tour and observed the facility maintains room temperature at 70°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 12/02/2024. Hot water temperature was measured at 110.5° Fahrenheit.

Continued on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

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: 02/24/2025

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Bedrooms: There are four (4) bedrooms, four (4) of which are designated for client use. One (1) bedroom is currently vacant. All the bedrooms were properly furnished with appropriate bedding, linens and sufficient lighting.

Bathrooms: There are two (2) bathrooms 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 hallway closet.

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 entrance and is maintained locked. Detergents were observed to be locked in laundry room.

Medications: Medication and Medication Records were reviewed for proper documentation for three (3) of three (3) clients.

Client Records: Client records were reviewed for proper documentation for three (3) out of three (3) 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. LPA also reviewed Infection Control Plan and verified that a yearly review was done.

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: 02/24/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2025

LIC809 (FAS) - (06/04)

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