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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530241
Report Date: 08/01/2024
Date Signed: 08/01/2024 10:30:22 AM

Document Has Been Signed on 08/01/2024 10:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WILDWOOD COURT LLCFACILITY NUMBER:
365530241
ADMINISTRATOR/
DIRECTOR:		WILLIS, TANYAFACILITY TYPE:
740
ADDRESS:11898 LUNA ROADTELEPHONE:
(951) 764-4633
CITY:VICTORVILLESTATE: CAZIP CODE:
92392
CAPACITY: 6CENSUS: 0DATE:
08/01/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Tanya Willis-LicenseeTIME VISIT/
INSPECTION COMPLETED:
10:40 AM
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Licensing Program Analysts (LPAs) Michelle Echeverria and Lavette Farlow , arrived at Wildwood Court LLC, to conduct an announced Pre-Licensing visit for licensure. LPAs were greeted by licensees, Tanya Willis and Jahmaal Willis. LPAs introduced self and stated purpose of the visit. LIC200 application was submitted on 04/19/24 for (5) non-ambulatory residents and (1) bedridden resident. Fire Safety Inspection clearance was granted for (5) non-ambulatory residents and (1) bedridden resident on 06/26/24. LPAs toured the facility inside and outside and observed the following:

Structure: Facility is a one story house with (4) resident bedrooms, (2) bathrooms, office, living room, (2) dining areas, kitchen, family room, laundry room, backyard, and attached garage.

Heating/Cooling System: Central heating and air conditioning system installed with a central panel located in the hallway to control entire house.

Bedrooms: Two bedrooms accommodates two non-ambulatory residents in each room, and one bedroom accommodates one non-ambulatory resident and one bedroom accommodates one bedridden resident.

Bathrooms: The bathrooms have a working toilet, wash basin, and shower with an adequate supply of toilet paper and soap.

Kitchen/Laundry: An adequate supply of dishes, glasses, utensils, pots, and pans were observed. Knives, sharps, detergent, and chemicals are stored in locked compartments. There was a pantry stocked with non-perishable food and perishable food found in the refrigerator. LPAs observed the stove to be operational. Refrigerator/freezer were in working condition. Water tested in the bathroom faucet measured at 107 degrees fahrenheit. A functional washer and dryer are located inside the laundry room.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/01/2024
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WILDWOOD COURT LLC
FACILITY NUMBER: 365530241
VISIT DATE: 08/01/2024
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Living/Family room: There was a furnished living room with books and games observed. There was a family room with a tv and an inaccessible fireplace observed.

Linens and Hygiene Supplies: An adequate supply of linens and hygiene supplies stored in a closet.

Yards/Outside: A shaded covered patio with (2) seating areas and a self-latching handle gate on the left side of the house that leads into the backyard were observed. There are no firearms, ammunition, swimming pool or bodies of water observed. All outdoor pathways were free of obstructions.

Emergency Phone Numbers, and Exit Plan: Facility sketch, CCL complaint poster, visitors policy, long-term ombudsman and personal rights were observed posted by the entrance.

General items: The smoke and carbon monoxide detectors were tested and are operable. There was a fully charged fire extinguisher observed. Resident/Staff records stored inside the locked filing cabinets in the office. First Aid kit with required components, and a locked compartment for medication storage was observed. The facility has a functioning telephone and line.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. LPAs completed COMP III with the Licensees at the conclusion of the inspection.

Licensees will be notified once facility is licensed. An exit interview was conducted, and this report was discussed and provided to licensees Tanya Willis and Jahmaal Willis.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:

DATE: 08/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/01/2024
LIC809 (FAS) - (06/04)
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