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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609942
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:03:18 PM

Document Has Been Signed on 10/15/2024 03:03 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:WILLOUBEE'S PARADISE LIGHTHOUSEFACILITY NUMBER:
197609942
ADMINISTRATOR/
DIRECTOR:		HERNANDEZ, JESSICA IFACILITY TYPE:
735
ADDRESS:6025 LIGHTHOUSE LANETELEPHONE:
(661) 350-3495
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 4DATE:
10/15/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Rashayla HayesTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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On 10/15/2024 Licensing Program Analyst (LPA) Lorena Casillas arrived at the facility above to conduct a Case Management - Legal/Non-compliance visit and inspection of the facility to ensure facility compliance. On January 17, 2023, a Non-Compliance Conference (NCC) was held at the Woodland Hills Regional office and as a result of that NCC, the facility was placed on a two year compliance plan.

LPA arrived at 10:10 am and was greeted by staff member. LPA called and spoke to Administrator who stated that House Manager (HM) Rashayla Hayes would be able to meet with LPA. HM arrived shortly after, and LPA explained the purpose of the visit.

Staff member informed LPA that three (3) out of four (4) clients were currently in their day programs. One (1) client was currently observed in their room sleeping.

At approximately 10:40 a.m., LPA and staff member took a tour of the physical plant.

Today’s focus was Capacity Determination, Food Service, Health Related Services, Building and Grounds, Limitations on Capacity and Ambulatory Status, Personal Rights, and Client Records.

LPA conducted a physical plant tour and observed the facility maintains a comfortable temperature of 73°F. The facility has four (4) bedrooms and two (2) bathrooms currently occupying four (4) clients. The facility is Fire Cleared for four (4) non-ambulatory. There is awake staff at night.



Continued on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: WILLOUBEE'S PARADISE LIGHTHOUSE
FACILITY NUMBER: 197609942
VISIT DATE: 10/15/2024
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Kitchen: LPA observed there to be sufficient stock of two-day perishable and seven-day non-perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed all knives and sharp objects locked and inaccessible to clients in care in the locked office. The fire extinguisher, located in the kitchen, was observed to be full and last serviced on 12/11/23. Medications were in a cabinet in the kitchen and was observed to be locked and inaccessible to clients in care.

Bedrooms: There are four (4) bedrooms all of which are designated for client use. All the bedrooms were properly furnished with appropriate bedding, linens and sufficient lighting.

Bathrooms: There are two (2) bathrooms that were properly supplied with paper towels, hand soap and had functional fixtures. Hot water temperature measured at 119 degrees Fahrenheit.

Common Areas: These included the living room and dining area. The common areas were properly furnished. Dining room and the living room are furnished with appropriate seating to comfortably seat the capacity of the facility.

Surrounding Grounds: Entry/exits were free of obstruction. The laundry room is located by the kitchen however door was not locked. Laundry detergent and cleaning supplies were observed to be unlocked and accessible to clients. LPA was informed that there is no key for the deadbolt lock on the kitchen door. LPA explained to HM that a citation would be issued. Please see LIC809-D.

Medications: Medication and Medication Records were reviewed for proper documentation for four (4) of four (4) clients.

Client Records: Resident records were reviewed for proper documentation for four (4) out of four (4) clients. There are currently three (3) ambulatory and one (1) non ambulatory clients in care.

Staff Records: LPA reviewed the LIC500 (Personnel Report) and found there to be sufficient staff for each shift. LPA also reviewed the staff training files. LPA verified that all staff have completed required training.

Citation issued.Appeals rights discussed and provided.Exit Interview Conducted.Copy of report was issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Lorena Casillas
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/15/2024 03:03 PM - It Cannot Be Edited


Created By: Lorena Casillas On 10/15/2024 at 02:10 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: 10/15/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/22/2024
Section Cited
CCR
80087(g)

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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:
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The HM agrees to provide training to all staff members regarding how to store hazardous items. HM will provide log of all staff members that have completed the training to LPA via email. The HM will have a locksmith install a new lock and will provide proof of repair by email to LPA by POC due date. .
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Based on observation, 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.
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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:Lorena Casillas
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024


LIC809 (FAS) - (06/04)
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