197609859-10-13-2022-31-AS-SSTS-CK6QF8-20221013120730

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 10/13/2022
Date Signed: 10/13/2022 12:08:05 PM

Document Has Been Signed on 10/13/2022 12:08 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

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:	DATE:	10/13/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:38 AM
MET WITH:	Jessica Hernandez, Administrator		TIME COMPLETED:	12:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Shira Stamps met with Administrator Jessica Hernandez for an unannounced one (1) year Required visit for this facility. LPA arrived at 10:38 am, but there was no answer at the door. LPA contacted the Administrator and she arrived at 11:05 am. All clients are attending their day programs. LPA informed the Administrator of the purpose of the visit. A tour of the physical plant was conducted with Administrator at 11:15 am. The facility has four (4) bedrooms and two (2) bathrooms currently occupying three (3) clients. One (1) bedroom is designated for staff use only. 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. Upon arrival LPA was screened by the Administrator and was signed-in; sanitizer was available. Food Inspection LPA conducted tour at the kitchen at 11:15am and observed there to be sufficient stock of two-day perishables and seven-day non-perishables foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPA observed all knives and sharp object 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. Resident Rooms LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each client. CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

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: 10/13/2022

NARRATIVE

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Bathrooms
At 11:17 am LPA observed all bathrooms to have the appropriated wash your hands signs posted. Hot water was tested and measured within regulation at 118.0 degrees F. LPA observed cleaning chemicals located under the sink, and one razor located in a draw accessible to clients in care

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

Physical environment
LPA toured the outside area of the facility at 11:24 am. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. No bodies of water on the premises.

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 78°F. The smoke detector and dual carbon monoxide detectors were tested and observed to be operational at 11:25 am. There is one (1) fire extinguisher located in the kitchen. The fire extinguisher was observed to be full but last serviced on 08/13/21. LPA viewed the confirmation text for an appointment set for Monday 10/17/22 for the fire extinguisher to be serviced through Fletcher Fire Protection. Due to short staff the company is behind on servicing fire extinguishers.

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

Administrative: LPA received the infection control plan on 6/16/22. The annual fee is not current, due 10/10/22.

An exit interview was conducted, citation issued, and a copy of this report and appeal rights was given to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/13/2022 12:08 PM - It Cannot Be Edited

Created By: Shira Stamps On 10/13/2022 at 11:54 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

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

FACILITY NAME: WILLOUBEE RESIDENTIAL III	FACILITY NUMBER: 197609859
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/13/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(G)

80087(g) Buildings and Grounds. Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in that cleaning solutions and a razor was accessible which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 10/17/2022
	Plan of Correction
1 2 3 4	The chemicals were immediately removed and locked. The Administrator states they will provide training for the section cited above to all staff, and will provide training materials and signatures of all staff that have completed the training by the POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Shira Stamps

LICENSING EVALUATOR SIGNATURE:

DATE: 10/13/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/13/2022

LIC809 (FAS) - (06/04)

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