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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609942
Report Date: 01/25/2022
Date Signed: 01/25/2022 04:42:42 PM

Document Has Been Signed on 01/25/2022 04:42 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'S PARADISE LIGHTHOUSEFACILITY NUMBER:
197609942
ADMINISTRATOR:HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:6025 LIGHTHOUSE LANETELEPHONE:
(661) 350-3495
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 2DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:10 PM
MET WITH:Henry Coleman, CaregiverTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Shira Stamps, with Caregiver Henry Coleman for an unannounced one (1) year Required visit for this facility.

LPA arrived at 2:10 pm, there was no answer at the door. LPA called the Designee Henry Coleman at 2:15 pm, and LPA left a message. LPA called the Administrator at 2:25 pm and the Administrator stated she would call the designee and have him come to the facility as soon as possible. The Caregiver arrived approximately at 3:20 pm. LPA informed the Caregiver of the purpose of the visit. All residents were at their day programs.

Infection control: LPA reviewed facility mitigation plan (approved on 03/14/21) to make sure the licensee was following current infection control recommendations. Upon arrival LPA was screened by the Caregiver and asked to answer all infection control questions. LPA was asked to sign-in and sanitize/wash hands.

A physical plant tour was conducted with the Caregiver at 3:30 pm. The facility has four (4) bedrooms and two (2) bathrooms currently occupying two (2) residents. The facility is Fire Cleared for four (4) non-ambulatory residents.

Resident Rooms
LPA observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident.

Laundry
At 3:50 pm, LPA observed the Laundry room located in the garage. LPA observed chemicals/hazardous items unlocked and accessible to residents in care. LPA informed the caregiver to place the chemicals in the locked cabinet above the laundry area. Continued...
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
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'S PARADISE LIGHTHOUSE
FACILITY NUMBER: 197609942
VISIT DATE: 01/25/2022
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Bathrooms
At 3:35 pm LPA observed all bathrooms to have non-skid matts, grab bars, and the appropriated wash your hands signs posted. The Hot water was tested at 3:40 pm and measured within regulation at 115.0 degrees F.

Food Inspection


LPA conducted a tour of the kitchen at 3:30 pm 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. Medications and chemicals/hazardous items were observed to be locked and inaccessible to residents in care.

Physical environment
LPA toured the outside area of the facility at 3:38 pm. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises.

Living and dining
At 3:32 pm, LPA observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature at 60°F. The smoke detectors and carbon monoxide detectors were tested and observed to be operational at 3:39 pm. There is one (1) fire extinguisher located in the kitchen. The Fire extinguisher was observed to be full and last serviced on 08/18/21.

Garage
At 3:50 pm, LPA observed the garage to be attached to the facility and currently being used for storage. LPA observed a locked staff area where extra PPE is kept.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 01/25/2022 04:42 PM - It Cannot Be Edited


Created By: Shira Stamps On 01/25/2022 at 04:26 PM
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'S PARADISE LIGHTHOUSE
FACILITY NUMBER: 197609942

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
80078(g)
80078(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
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Based on obersvation, the licensee did not comply with the section cited above in that the LPA observed cleaning solutions/disinfectants not locked in the garage, which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/04/2022
Plan of Correction
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The Licensee agrees to provide training to all staff members regarding how to store disinfectants, cleaning solutions, hazardous items, and chemicals. The Licensee will provide signatures of all staff members that have completed the training. Staff secured all chemicals/ cleaning solutions during today's visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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: 01/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/25/2022


LIC809 (FAS) - (06/04)
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