<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609956
Report Date: 06/07/2021
Date Signed: 06/07/2021 01:08:15 PM

Document Has Been Signed on 06/07/2021 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DESERT WILLOW HOMEFACILITY NUMBER:
197609956
ADMINISTRATOR:LOPEZ, MONIQUEFACILITY TYPE:
735
ADDRESS:4125 W AVENUE DTELEPHONE:
(805) 544-5332
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 0DATE:
06/07/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Monique Lopez/ AdministratorTIME COMPLETED:
01:25 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analysts (LPA) Patrick Shanahan and Melissa Ruiz conducted a Pre-Licensing Visit & Inspection and Comp III. Regional Center representatives Nancy Salyers and Venus Rodriguez - Kohrasani were also in attendance. This is a new Applicant Representative,

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. First-aid kit is complete; facility has adequate linen, perishable and nonperishable food supplies. Hot water measured at 108 degrees Fahrenheit. There is no swimming pool or other body of water. The backyard is fenced and gated with self-latching mechanisms. There is patio area in the backyard with table and chairs for resident use. All chemicals and sharps are stored in a locked cabinet. Medications are stored in a locked cabinet across from the office. Facility has 4 bedrooms and 2 bathrooms with one staff office. Fire Clearance is approved for 4 non ambulatory residents and 0 bedridden. There are 4 single rooms and no shared rooms. The washer and dryer are located next to the office and kitchen.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Unit (CAU). You will be notified by the CAU Analyst when your license has been approved.
You are not allowed to begin operating until you have been notified that your license has been approved by the CAU Analyst. Failure to comply could affect approval of your license.
Exit interview held and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2021
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 1