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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609647
Report Date: 12/03/2021
Date Signed: 12/03/2021 01:52:19 PM

Document Has Been Signed on 12/03/2021 01:52 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:WHITE'S ADULT HOME LLCFACILITY NUMBER:
197609647
ADMINISTRATOR:WHITE, EDMONDFACILITY TYPE:
735
ADDRESS:4054 TOURNAMENT DRTELEPHONE:
(661) 526-3088
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
12/03/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Jaqueline TorresTIME COMPLETED:
02:00 PM
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LPA Spaeth conducted an unannounced annual visit and arrived at 1:00 pm, Upon approaching the front door, LPA observed the COVID sign. LPA was greeted by caregiver, Jaqueline Torres who was wearing a mask. LPA's temperature was taken, COVID questions answered and LPA signed in. The caregiver requested LPA to use the hand sanitizer upon entering the facility. Caregiver Andy Brandt was also wearing a mask.

LPA and Caregiver began the tour at 1:06 pm. LPA observed the living room which was contained comfortable seating. A formal dining room contained a dining room table and chairs. LPA was escorted to another dining room area, kitchen and family room combination. This area contained a dining room table with chairs, comfortable seating, and the kitchen.

The kitchen was clean and the sink area contained wash your hands sign, paper towels, hand soap, and trash can. The refrigerator contained fresh fruits and vegetables, dairy products, and drinks. The freezer section contained an adequate supply of frozen meats. LPA observed there were no cleaning supplies underneath the sink. The pantry contained an adequate supply of canned goods. A locked hallway closet contained the resident medications, the knives, and a 90-day supply of PPE. LPA observed the locked garage which contained locked cabinets with the cleaning supplies and additional PPE. LPA went to the backyard and observed a shaded area with comfortable patio furniture and the side gate was not locked.

LPA observed one resident room and a staff room on the first floor along with a resident bathroom. The resident room contained lamp, lamp stand, chest of drawers, a bed and linens. The bathroom contained wash you hands sign, hand soap, paper towels, and a trash can. Both parties then proceeded to the second floor and LPA observed three resident rooms and the master bedroom. All resident rooms were clean and contained the required furnishings. The second floor bathroom also was furnished with hand soap, paper towels, wash your hands sign and a trash can. The LPA observed the locked laundry room.
There are no deficiencies; appeal rights discussed, and a copy of the signed report given to the caregiver.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2021
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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