197610372-5-15-2024-31-AS-MCAA-D5B2XR-20240515174735

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610372
Report Date: 05/15/2024
Date Signed: 05/15/2024 05:48:18 PM

Document Has Been Signed on 05/15/2024 05:48 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/ DIRECTOR:	ANGUIANO, EMALYN		FACILITY TYPE:	740
ADDRESS:	44148 12TH ST WEST		TELEPHONE:	(661) 418-6180
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 6		CENSUS: 2	DATE:	05/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	02:39 PM
MET WITH:	Rosebella "Bella" Hugal		TIME VISIT/ INSPECTION COMPLETED:	05:45 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	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Rosebella “Bella” Hugal, and explained the reason for the visit. At approximately 2:45pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide are dual, hardwired and interconnected. There are two fire extinguishers. One is located in the kitchen, and the other is located in at the enclosed patio area. The charge date is March 4, 2024. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning supplies were stored locked underneath the kitchen sink. Bedrooms: There are four (4) bedrooms designated for residents' use. Two (2) bedrooms are shared and two are private. Currently there are two (2) private residents in care. Bedrooms, in use by the residents and the vacant rooms, were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 109 and 114 degrees Fahrenheit. No cleaning supplies were observed in either bathrooms during the day of the inspection. Common Areas: These included the living room and dining area. The living room was furnished with four recliners, two tables and television. The dining room table is large enough to seat up to six (6) individuals. Living room and dining room furniture where in good repair. Floors were mopped and clean. Exits and passageways were clear.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOWVIEW HOME TWO, LLC	FACILITY NUMBER: 197610372
	VISIT DATE: 05/15/2024

NARRATIVE

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Surrounding Grounds: Entry/exits to the front and back yards were free of obstruction. There is an enclosed patio area where activities can be held, and a glass door, which leads to the backyard. There is a storage building in the backyard that stores PPE supplies. The outdoor area was free of hazards. Gates at both sides of the home presents no exterior lock and is clear to exit/evacuate in case of an emergency.

Laundry area: The laundry area is located at the corner of the enclosed patio. Toxins and detergents not present at this time.

Staff Workstation/Office: There is a staff workstation located at the enclosed patio, adjacent to the laundry area.

Resident Files: Resident files are kept locked in the medication closet. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are also kept locked in the medication closet. LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are stored in a locked closet by the living room (medication closet). In addition, there is a locked drawer in the kitchen that licensee also stores medications in. Medication and Medication Records were reviewed for proper storage and documentation.

Garage: The garage is attached to the building. It was converted into a room, but is also used as storage. Room was already built, and permit was already obtained prior to purchase of the property. Only entry is at the side, which has a locked door and no resident access.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 05/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/15/2024

LIC809 (FAS) - (06/04)

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