197610372-3-7-2023-31-AS-SSTS-CPPUEV-20230307143147

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610372
Report Date: 03/07/2023
Date Signed: 03/07/2023 02:32:41 PM

Document Has Been Signed on 03/07/2023 02:32 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:	WILLOWVIEW HOME TWO, LLC		FACILITY NUMBER:	197610372
ADMINISTRATOR:	ANGUIANO, EMALYN		FACILITY TYPE:	740
ADDRESS:	44148 12TH ST WEST		TELEPHONE:	(661) 418-6180
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 6		CENSUS: 1	DATE:	03/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:40 AM
MET WITH:	Emalyn Anguiano, Licensee		TIME COMPLETED:	02:45 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

Willowview Home II: Licensing Program Analyst (LPA) Shira Stamps met with Emalyn Anguiano (Licensee/Applicant) for a Pre-licensing inspection at 11:40 pm.

Entrance interview conducted.

The home is designed for a capacity of six (6) residents, four (4) ambulatory, two (2) non ambulatory, and zero (0) bedridden. Staff will be awake at night.

The physical plant was toured inside and out at 11:55 am.

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 71 degrees F, which meet regulations. No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detectors were operational and tested at 12:26 pm. Fire extinguishers appear to be full, and last serviced 7/05/2022

Resident rooms: Rooms available are both private and shared. LPA observed rooms to have bedding sheets, comforters, mattress pads and pillowcase, which are in good condition. There is at least one chair, a night stand, and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition. Window covering and window screens are in good repair. Room #2 has a cracked window and needs to be replaced. The back living room area was previously converted and is designated for staff use only and will remain locked at all times. The laundry room is also located in the back living room area. LPA tested the auditory system on all exit doors, and is working properly.

CONTINUED...

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

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 3

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: WILLOWVIEW HOME TWO, LLC	FACILITY NUMBER: 197610372
	VISIT DATE: 03/07/2023

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
26
27
28
29
30
31
32

Residents will have sufficient amounts of supplies for personal hygiene products, which is provided by the Licensee.

Bathrooms: LPA toured residents bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 111.5. The Licensee has appropriate non-skid mat in each shower, grab bars, and trash cans with lids. Towels and washcloths will not be shared.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible in the kitchen cabinet under the sink.

Medications will be kept centrally stored and locked in a closet located in the entry way. Stove and refrigerator are clean and in good operation. LPA observed sufficient supply of 7- day non-perishable and perishable foods.

Outside: LPA toured the outside area. LPA did not observe a covered shaded area for residents. No bodies of water observed on the premises. LPA observed a shed used for storage, no hazardous items will be stored in the shed. LPA observed old doors, washer machine, paint buckets, and old fencing stored on the side of the house. The Licensee stated her maintenance personnel is in the process of removing the items.

Garage: There is no garage.

Files will be kept confidentially stored in the locked entry way closet.

LPA discussed preplacement, staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations.

Applicant/ Administrator has completed component III.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: WILLOWVIEW HOME TWO, LLC	FACILITY NUMBER: 197610372
	VISIT DATE: 03/07/2023

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
26
27
28
29
30
31
32

The licensee will need to complete the following before the license is approved.

1. Replace room #2 bedroom window. Submit a photo.

2. Replace side gate. Submit a photo.

3. Remove tripping hazards outside in the backyard and the side of the house. Submit a photo.

4. Provide outdoor furniture with covered shaded area. Submit a photo.

5. Clean or remove staff freezer. Submit a photo.

The facility is ready for operation upon correction of requested items in this report, and final approval of the application. Submit items for correct

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE:	DATE: 03/07/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/07/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3