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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 08/19/2021
Date Signed: 08/19/2021 11:50:56 AM

Document Has Been Signed on 08/19/2021 11:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		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 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:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Jessica HernandezTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility at 9:01am to conduct a One (1) year Required Infection Control visit. LPA meet with the Director Jessica Hernandez explained the purpose of this visit.
A tour of the physical plant was conducted at 9:45am and the following was observed:

The facility has one main entrance being used, there are required Covid-19 prevention signage (hand washing, coughing etiquette) posted. The PPE screening is conducted upon entrance at the front door. Sufficient PPE is readily kept on the kitchen counter and is presented upon entrance, thermometer, hand sanitizer, gloves, mask and sign in sheet located on the wall at the front door at the time of visit The facility maintains a comfortable temperature of 80 degrees F. Visitor are allowed in the outdoor patio seating area after the screening process is complete.

The facility has an approved mitigation plan on file.

Kitchen: At 9:50am LPA observed the kitchen to be clean and an adequate supply of two (2) day perishables and (7) days non-perishable food located in the fridge, freezer and pantry. Food was properly labeled and stored. Food storage and preparation areas are clean and inaccessible to pests. Sharps are stored in the kitchen cabinet below the counter top next to the stove inaccessible to residents and observed to be locked. The emergency food is stored in the garage connected to the home which was observed to be locked. Toxins and soap were observed to be locked in a kitchen cabinet underneath the sink.

(Continued on LIC 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE RESIDENTIAL III
FACILITY NUMBER: 197609859
VISIT DATE: 08/19/2021
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Medication: At 10:05am LPA observed the medication stored in a kitchen cabinet adjacent to the stove which was observed to be locked. The facility First Aid kit is stored in the same kitchen cabinet as the medication, which was observed to be locked.


Laundry Room: At 10:12am LPA observed the laundry room to be clean and clear from obstruction. Laundry soap, toxins and poisons observed to be locked and stored in the laundry room. Extra linen is stored in a closet adjacent to the kitchen and towels are stored in the bathrooms.
(Continued on LIC 809C)

Bathrooms: At 10:27am LPA observed (2) bathrooms for residents use. One bathroom located in a vacant room which has two (2) sinks measured at 117.9 and 118.8. In the second bathroom the water temperature measured 117.3. Bathrooms observed to be clean and have sufficient soap and paper towels, hand towels are not shared.

Client Rooms: LPA at 10:42am observed four (4) bedrooms three (3) are designated for resident use and one (1) is used for staff office. 3 out of 4 bedrooms observed to have sufficient lighting and are properly furnished and observed to be clean and have appropriate bedding and linens. The staff designated room was observed to have PPE, toiletries and purchased furniture for residents use that required assembling which was observed to be locked.


Living, dining room and common areas: Observed to have television, sofa and love seat for seating with sufficient lighting. Observed to be clean and in good repair. Employee and resident files were observed to be locked and kept in a file cabinet the dining room against the wall.

Backyard: At 11:00am LPA observed the back yard to have a shaded area near the exit with tables and chair for seating. The outside area and around the building of the facility observed to be clean and clear of debris. No bodies of water observed on the property.

At 11:08am the fire alarm system was tested and observed to be working, it is hard wired and inter-connected. The fire Extinguisher is located near the kitchen sink on the wall service tag dated August 13, 2021.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: LaQueena Lacy
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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