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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609647
Report Date: 12/15/2022
Date Signed: 12/15/2022 09:16:14 AM

Document Has Been Signed on 12/15/2022 09:16 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
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:
12/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:15 AM
MET WITH:Jaqueline TorresTIME COMPLETED:
09:15 AM
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LPA Spaeth conducted an unannounced annual visit and arrived at 8:15 am, 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. LPA stated the purpose of the visit. Caregiver confirmed there are four residents. LPA observed two residents waiting for van pick-up for the adult program and Caregiver stated two residents had already left the facility to attend an adult day program. . LPA observed caregiver prepared resident's lunch and escorted residents to the van.

LPA and Caregiver began the tour at 8:45 am. 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 a 2 day supply of perishable foods and the pantry contained a 7 day supply of non perishable items. The freezer section contained an adequate supply of frozen meats. LPA observed there were no cleaning supplies underneath the sink. 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.

There are four residents' rooms; two on the first floor and 2 on the second floor. The residents' room contained lamp, lamp stand, chest of drawers, a bed and linens. All three bathrooms contained wash you hands sign, hand soap, paper towels, & trash can. The LPA observed the locked laundry room. The linen closet was located upstairs.
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: 12/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2022
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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