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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:22:52 PM

Document Has Been Signed on 01/13/2023 03:22 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 IIIFACILITY NUMBER:
197609859
ADMINISTRATOR:HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:3631 E GARNET LANETELEPHONE:
(661) 350-3495
CITY:LANCASTERSTATE: CAZIP CODE:
93535
CAPACITY: 4CENSUS: 3DATE:
01/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Kelly RossTIME COMPLETED:
02:30 PM
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LPA Spaeth conducted an unannounced visit and was greeted by the caregiver (S1). LPA stated the purpose of the visit is to complete a case management visit to follow up on food service and care/supervision. LPA observed S1 was wearing a mask. LPA's temperature was checked and LPA was asked to sign in and answer the COVID questions at the sign in station. S1 confirmed there are three residents. One resident was asleep in room, one resident was eating lunch, and the third resident was away from the facility. LPA toured the facility with S1 at 12:30 am until 12:55 am. LPA viewed residents' files at at 1:45 until 2:15pm. During LPA's tour LPA observed the following:

Common areas - LPA observed the living room, dining room, and kitchen are all combined as one large room. Within the living room section, LPA observed comfortable seating along with a television set. The dining room section contained dining room table and chairs.

Kitchen – LPA observed the medications, knives, hygiene items and the first aid kit were safely locked in the kitchen. The cleaning supplies were locked underneath the kitchen sink. Paper towels and hand soap were located at the kitchen sink. LPA viewed the refrigerator and pantry. LPA observed a seven day supply of non-perishable items and a two day supply of perishable items. LPA also observed the kitchen was neat and clean.

Residents’ rooms - LPA observed one resident’s room which contained a bed, linens, lamp, lamp stand, chest of drawers and closet.



Bathrooms - There are two bathrooms in the facility. LPA was able to view one bathroom. The bathroom contained hand soap, paper towels, and trash can. There were no safety issues to report. LPA was informed the second bathroom is in the master bedroom. A residents was resting in the master bedroom.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/13/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 01/13/2023
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Backyard- LPA observed the side gate leading from the backyard to the front yard was not locked. There were no safety issues to report.

Laundry Room – LPA observed the locked laundry room with the washer/dryer. The laundry detergent was locked in a cabinet.

Garage – LPA observed the garage was locked and a 90-day supply of PPE.

There are no deficiencies to report at this time. Exit interview was conducted and a copy of the signed report was given to the Caregiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 01/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023
LIC809 (FAS) - (06/04)
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