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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609942
Report Date: 01/13/2023
Date Signed: 01/13/2023 03:25:30 PM

Document Has Been Signed on 01/13/2023 03:25 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: DATE:
01/13/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
07:40 AM
MET WITH:Ronald WilbertTIME COMPLETED:
10:30 AM
NARRATIVE
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LPA Spaeth conducted an unannounced visit and was greeted by the Facility Manager (S1). LPA stated the purpose of the visit was to conduct a case management visit. 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 four residents. One resident was in room and the other three residents had left to attend the adult program. LPA toured the facility with S1 at 8:00 am until 8:30 am. LPA viewed residents' files at 8:45 am until 9:15 am. During LPA's tour LPA observed the following:

Common areas - LPA observed the living room contained comfortable seating along with a television set.

Residents’ rooms - LPA observed the four rooms which contained bed, linens, lamp, night stand, chest of drawers and closet.

Bathrooms - LPA observed the two bathrooms contained hand soap, paper towels, and trash can. There were no safety issues to report.

Backyard- LPA observed the side gate leading from the backyard to the front yard was not locked. There were no safety issues to report.

Hallway – LPA observed a hallway closet which contained clean linens

Garage – LPA observed the garage was locked and contained washer/dryer and the laundry detergent was locked. The Administrator’s office was also in the garage & the residents’ files were locked in a cabinet.
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)
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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: 01/13/2023
NARRATIVE
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Kitchen – LPA observed the medications and the first aid kit was locked in a kitchen cabinet. The cleaning supplies were locked underneath the kitchen sink. S1 stated there are no knives in the facility due to the physical conditions of the residents. Paper towels and hand soap was located at the kitchen sink. LPA viewed the refrigerator and pantry. S1 stated food would be dropped off today; however LPA observed there was not a seven-day supply of non-perishable food. Pursuant to Title 22 Division 6 of the CA Code of Regulations, a deficiency was cited (refer to LIC 809-D).

Exit interview conducted, Appeal Rights discussed, and a copy of the report was given to S1.
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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Document Has Been Signed on 01/13/2023 03:25 PM - It Cannot Be Edited


Created By: Melissa Spaeth On 01/13/2023 at 09:54 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'S PARADISE LIGHTHOUSE
FACILITY NUMBER: 197609942

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/13/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/13/2023
Section Cited
CCR
85076(d)(1)

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85076 (d) The licensee shall meet the following food supply and storage requirements: (1) Supplies of staple nonperishable foods for a minimum of one week & fresh perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
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During LPA's visit, LPA observed food delivered to the facility including non-perishable food snacks and perishable food items were delivered.
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Based on LPA's observations, the facility has a shortage of non-perishable food items which poses an immediate health, safety, or personal rights risk to persons in care.
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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:Cassandra Harris
LICENSING EVALUATOR NAME:Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:
DATE: 01/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/13/2023


LIC809 (FAS) - (06/04)
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