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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609956
Report Date: 07/02/2025
Date Signed: 07/02/2025 12:49:32 PM

Document Has Been Signed on 07/02/2025 12:49 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:
07/02/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Ashely Spillers / House ManagerTIME VISIT/
INSPECTION COMPLETED:
12:48 PM
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On 07/02/25 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 house manager Ashely Spillers and informed them LPA was at the facility. The house manager met LPA shortly after. LPA Rios explained the purpose of the visit. The interim administrator is Monique Lopez.

At approximately 9:10 a.m., LPA Rios conducted a physical plant tour of the facility inside and out. The following was observed: LPA observed appropriate 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. LPA found a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Knives and sharps were stored in two (02) locked kitchen drawers. Cleaning supplies were locked in a kitchen cabinet away from food.

Bedrooms: There are four (04) 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 73 degrees Fahrenheit. LPA observed auditory alarms on all exit doors which were on and functional at the time of the visit.

Bathrooms: There are two (2) bathrooms. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was taken from one (01) bathroom and read 110.7 degrees Fahrenheit within regulation. (Continued on LIC809-C)
NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/02/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 07/02/2025
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Laundry: The laundry area is accessible to clients in care. The washer and dryer were in use and observed to be functioning properly. Detergents and cleaning products are kept locked in cabinets by the washer and dryer. Cabinets in this area also had extra linens and hygiene products.

Common Areas: These included the living room, dining area, work space, and activity room. The common areas were clean, clear of clutter and properly furnished. Dining table and couches sit the capacity of the facility. The work space has a computer, printer, scanner and board games for clients to use. The activity room is behind the facility and was observed locked. Next to the activity room is a room used for storage. LPA observed emergency supplies such as water, food and PPE.

Surrounding Grounds: Entry and exits were free of obstructions. The outdoor area was free of hazards. There is a shaded area for clients. No bodies of water observed.

Client Files: At 9:47 a.m., LPA conducted a file review of four (4) out of four (4) client records. LPA observed clients have attended medical appointments regularly and have up to date appraisals. No issues observed. Staff Files and Facility File: At 11:12 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. LPA reviewed facility records and observed the last earthquake drill conducted on January 2025 and a fire drill conducted on February 2025. LPA obtained a copy of facility's personnel report, liability insurance certificate and the register of facility clients. No issues observed.

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 the pharmacy.

The smoke alarms are hard wired and interconnected. The house manger tested the smoke detectors/carbon monoxide detector at 12:03 p.m. and they were observed to be functioning properly. LPA observed fire extinguishers located through out the facility fully charged with service date of 05/25.

No deficiencies observed during todays visit. Exit Interview Conducted. A copy of the report Issued.

NAME OF LICENSING PROGRAM MANAGER: Eva Miller
NAME OF LICENSING PROGRAM ANALYST: Evelin Rios
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/02/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2025
LIC809 (FAS) - (06/04)
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