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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609956
Report Date: 06/27/2022
Date Signed: 06/28/2022 03:25:07 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/28/2022 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: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: 4DATE:
06/27/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Monique LopezTIME COMPLETED:
11:50 AM
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At 10:30 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA observed covid-19 signage posted outside the facility. LPA was greeted by a staff member and granted access to the facility. Staff prompted LPA to check in. LPA observed a visitor’s check in station which consists of sign in logs, thermometers, and hand sanitizer. PPE supplies were readily available. LPA later met with house manager Merari Pina-Aguilar. An entrance interview was conducted. The purpose of the visit was explained.
At 10:35 a.m., LPA initiated a physical plant tour. This is a four (4) bedroom two (2) bathroom Adult Residential Facility, vendored by North Los Angeles Regional Center. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. Various fire extinguishers were observed, and they are inspected monthly. The last inspection being May 2022. Smoke detectors and carbon monoxide monitors were observed to be functional. LPA observed there to be sufficient stock of
one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Extra towels and linens were readily available. Bathrooms have soap, paper towels and trash cans with lids. Bedrooms are clean and have appropriate furniture. The backyard is clean, has a covered shaded areas. There is a designated game room in the backyard that is connected to the garage. No bodies of water.

(cont. on 809-C)
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/28/2022
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: DESERT WILLOW HOME
FACILITY NUMBER: 197609956
VISIT DATE: 06/27/2022
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Administrative: LPA was advised by the Administrator Monique Lopez that the facility is undergoing a change of Administrator. The new Administrator will be Merari Pina-Aguilar. LPA requested the following documents to be provided to the Woodland Hills Regional Office:
  • E-mail address and emergency phone number
  • LIC 308
  • LIC 508
  • LIC 501
  • LIC 500
  • Board Resolution
  • CPR, First Aid Certification, TB test

All of the documents requested above shall be mailed and or dropped off at the Regional Office by 7/5/2022 and addressed to:
Melissa Ruiz, LPA
21731 Ventura Blvd Suite 250
Woodland Hills CA 91364
No deficiencies issued during today’s visit. Report was signed and delivered. An exit interview was conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:

DATE: 06/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022
LIC809 (FAS) - (06/04)
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