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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609956
Report Date: 11/29/2023
Date Signed: 11/29/2023 02:05:38 PM

Document Has Been Signed on 11/29/2023 02:05 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
N LA & CEN COA AC/SC, 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:
11/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Jessica HatleyTIME COMPLETED:
02:15 PM
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On 11/29/2023 at 10:00 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced required annual inspection. LPA observed appropriate Covid-19 postings on the outside of the front door. LPA was greeted by staff #1(S1) Elizabeth Paredes and granted access. S1 requested LPA to sign. S1 informed LPA the Administrator Jessica Hatley was already on their way to this facility. LPA met with administrator shortly after and LPA explained the reason for the visit. Entrance Interview conducted.
The facility has four (4) bedrooms and two (2) bathrooms. The facility is Fire Cleared for four (4) ambulatory.

A tour of the physical plant was conducted with administrator at approximately 10:15 a.m. and the following was observed: LPA observed required postings through out the facility.

Food Inspection: LPA conducted a tour of the kitchen at approximately 10:15 a.m. and observed there to be sufficient supply of two-day perishables and seven-day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPAs observed all knives, sharp object, locked in kitchen drawers inaccessible to clients in care.

Living and dining areas: LPA observed the living area and dining area to be clean and clear of clutter. The furniture was in good repair and sits the capacity of the facility. At 10:26 a.m. LPA observed Administrator test a smoke detector. Detector is interconnected to other detectors located through out the facility. Carbon monoxide detector was observed to be functioning properly. There are fire extinguishers located through out the facility observed to be fully charged with last serviced date 10/23/2023.

Bedrooms: LPA inspected four (4) out of four (4) client bedrooms. Bedrooms are for private use. LPA observed each client room to be properly furnished with one bed, appropriate night stand, chair, bedding and with sufficient lighting and storage. LPA observed extra linens in the office. (Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2023
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DESERT WILLOW HOME
FACILITY NUMBER: 197609956
VISIT DATE: 11/29/2023
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(Continued from LIC809)
Bathrooms: The facility has 2 bathrooms. The LPA took water temperature from one (1) out two (2) bathrooms and temperature was 110.8 degrees F. LPA observed the bathrooms to be clean and properly supplied with hand soap, toilet paper, paper towels and trash bins with lids.

Laundry: Laundry area is located by the office and is accessible to clients and staff. Detergents are kept locked in a cabinet by the laundry appliances.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture for clients to use. There is a recreation room detached from the facility. Attached to the recreation room is a storage room with emergency food, water and supplies for a disaster.

Client/Staff Records: At approximately 11:00 a.m. four (4) out four (4) client records and (2) staff records were reviewed to insure compliance with licensing forms. Records are kept locked in filing cabinets in the facility office.

Medications: Centrally stored medications are maintained in locked cabinets by the facility office. Medications were observed locked. One pharmacy is being utilized for resident use. Refills are either done automatically or ordered by the physician. Medication Records were reviewed for proper documentation. Medication records are maintained both electronically and manually.

Client/Staff Interviews: At 12:45 p.m. LPA conducted interviews with staff and clients present at the facility.

Pursuant to Title 22 Division of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE:

DATE: 11/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/29/2023
LIC809 (FAS) - (06/04)
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