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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609859
Report Date: 07/20/2023
Date Signed: 07/20/2023 01:08:03 PM

Document Has Been Signed on 07/20/2023 01:08 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
WOODLAND HILLS S.ASC, 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:
07/20/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Jesica HernandezTIME COMPLETED:
11:45 AM
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LPA Spaeth conducted an unannounced visit and was greeted by Administrator. Administrator confirmed there are three residents living in the facility. LPA Spaeth and the administrator conducted a tour of the facility at 11:00 am until 11:27 am.

Kitchen – LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable food items. The knives, hygiene items, & medications were locked in a kitchen cabinet. The cleaning solutions were locked underneath the sink. LPA observed hand soap, paper towels, fire extinguisher, and a trash can.

Garage- LPA observed the door leading to the garage was locked & contained emergency food supply.

Laundry Room – The room was locked and laundry detergent and additional hygiene items.

Outdoor area – LPA observed comfortable seating & the side gate was not locked.

Common areas – LPA observed comfortable dining room furniture in the kitchen and the living room contained comfortable seating along with a television.

Residents’ Bedrooms – All rooms contained bed, linens, night stand, a lamp, and closets for storing clothing.

Bathrooms – There are two bathrooms which both contained a trash can, hand soap, and paper towels.

Linens – LPA observed the linen closet located in the hallway which contained an adequate supply of linens.

Smoke/Carbon Monoxide Detectors – The smoke/carbon monoxide detectors were tested at 11:25 am and LPA observed the detectors were operable.

There are no deficiencies to report. Exit interview conducted, and a copy of the signed report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
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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