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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609956
Report Date: 07/09/2024
Date Signed: 07/09/2024 04:20:53 PM

Document Has Been Signed on 07/09/2024 04:20 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/
DIRECTOR:		HATLEY, JESSICAFACILITY TYPE:
735
ADDRESS:4125 W AVENUE DTELEPHONE:
(661) 723-5745
CITY:LANCASTERSTATE: CAZIP CODE:
93536
CAPACITY: 4CENSUS: 4DATE:
07/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:30 PM
MET WITH:Jessica Hatley (Administrator)TIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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On 07/09/24 Licensing Program Analyst (LPA) Evelin Rios arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff. Staff contacted the administrator Jessica Hatley and informed them LPA was at the facility. Administrator, Jessica Hatley met LPA shortly after. LPA Rios explained the purpose of the visit. This is a four (4) bedroom two (2) bathroom, Adult Residential Facility. Facility has an approved fire clearance for 4 non ambulatory clients for a total capacity of 4.

At approximately 1:40 p.m. LPA conducted a physical plant of the facility inside and out. The following was observed:

LPA observed required postings by the common areas and a visitor sign-in log upon entry.

Kitchen: The kitchen was clean and clear of clutter. Kitchen appliances and fixtures were observed functional. Administrator was out purchasing groceries during tour. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen.

Bedrooms: There were four (4) private bedrooms designated for clients. Bedrooms were properly furnished with appropriate bedding, linens, sufficient lighting and required furniture. The facility keeps a comfortable temperature of 71 degrees Fahrenheit.

Bathrooms: There are two (2) bathrooms. One (1) is located in the office. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (1) bathroom at 2:07 p.m. and read 114 degrees Fahrenheit within compliance.

(Continued on LIC809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Evelin Rios
LICENSING EVALUATOR SIGNATURE: DATE: 06/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/18/2024
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
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: 07/09/2024
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Laundry: The laundry area is accessible to clients in care. Detergents and cleaning products are kept in locked in cabinets by the washer and dryer. Cabinets in this area also had extra linens stored.

Common Areas: These included the living room and dining area. The common areas were clean, clear of clutter and properly furnished. Dining table and couches sit the capacity of the facility. LPA observed auditory alarms on all exit doors which were on and functional at the time of the visit.

Surrounding Grounds: Entry/exits were free of obstructions. The outdoor area was free of hazards. There is a shaded area for clients. LPA observed a locked building behind the facility being used as an activity room and storage for emergency supplies such as water, food and PPE.

The smoke alarms are hard wired and interconnected. Administrator tested the smoke detectors at 2:28 p.m. and they were observed to be functioning properly. LPA observed four (4) fire extinguishers located through out the facility fully charged with service date 06/2024.

Medications: At 2:49 p.m. Medication was observed locked in a cabinet by the office. Medication Records were reviewed for proper documentation. Facility keeps electronic records and receives Centrally Stored Medications and Destruction records from pharmacy.

Staff Files and Facility File: At 2:50 p.m. LPA conducted a file review of four (4) staff records and facility records to insure forms and training are up to date and in compliance with licensing forms. No issues observed.

Client Files: At 3:25 p.m. LPA conducted a file review of four (4) out of four (4) client records to insure compliance of licensing forms. No issues observed.


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: 07/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024
LIC809 (FAS) - (06/04)
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