197609647-12-14-2023-31-AS-MSPH-CYHUPM-20231214144545

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609647
Report Date: 12/14/2023
Date Signed: 12/14/2023 02:45:52 PM

Document Has Been Signed on 12/14/2023 02:45 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WHITE'S ADULT HOME LLC		FACILITY NUMBER:	197609647
ADMINISTRATOR:	WHITE, EDMOND		FACILITY TYPE:	735
ADDRESS:	4054 TOURNAMENT DR		TELEPHONE:	(661) 526-3088
CITY:	PALMDALE	STATE: CA	ZIP CODE:	93551
CAPACITY: 4		CENSUS: 2	DATE:	12/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Melvin Henriquez		TIME COMPLETED:	12:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/14/2023. LPA was greeted by the caregiver. The caregiver spoke to the Administrator via phone call and the Administrator confirmed the caregiver will accompany LPA for the tour of the facility. The facility is licensed for four ambulatory clients and there are four clients living in the facility.

LPA Spaeth and the caregiver began the tour at 9:10 am until 9:40 am. LPA observed the following:

Common areas – The living room and family room contained comfortable seating. A television is located in the family room. The dining room contained a dining room table and chairs.

Hallway closet- LPA observed the clients’ files and medications were stored in the closet along with the knives, PPE supplies, first aid kit, and emergency food.

Kitchen – LPA observed a two day supply of perishable food and a seven day supply of non-perishable food. There were no cleaning solutions stored underneath the kitchen sink. A fire extinguisher is located near the kitchen area and was operable. The kitchen was neat and clean.

Garage – The garage was locked and contained the cleaning solutions.

Backyard – There is a shaded seating area in the backyard. The gate leading from the backyard to the front yard was not locked.

Resident Rooms - LPA observed the resident rooms contained bed, linens, night stand, lamp, closet and chest of drawers. All rooms were neat and clean.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WHITE'S ADULT HOME LLC	FACILITY NUMBER: 197609647
	VISIT DATE: 12/14/2023

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Laundry Area - The laundry room was locked and contained the washer and dryer.

Bathrooms – LPA observed the bathroom contained hand soap, paper towels, and covered trash cans. The water temperature was tested at 9:25 am and was 116.1 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 9:30 am and were operable.

LPA reviewed client records at 9:50 until 10:20 am. LPA also reviewed staff records at 10:30 am until 11:00 am. LPA checked resident medications at 11:00 am until 11:15 am.

LPA requested to review the client P&I funds; however, the caregiver did not have access to the locked location of the funds.

Based upon Title 22 regulations, the following citation was issued and recorded on the attached LIC 809D.

Exit interview conducted, appeal rights provided to the caregiver, and a copy of the signed report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:	DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 12/14/2023 02:45 PM - It Cannot Be Edited

Created By: Melissa Spaeth On 12/14/2023 at 11:31 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WHITE'S ADULT HOME LLC	FACILITY NUMBER: 197609647
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 12/14/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80044(c)(1)

80044(c)(1) The licensee shall ensure that provisions are made for the examination of all records relating to the operation of the facility. This requirement is not met as evidenced by: During the visit, the P&I client's monies were locked and not available to CCL staff for inspection.
	Deficient Practice Statement
1 2 3 4	Based on LPA Spaeth's observation, the licensee did not comply with the section cited above in providing LPA's access to the P&I cash which poses a personal rights risk to persons in care.
	POC Due Date: 12/20/2023
	Plan of Correction
1 2 3 4	Licensee shall provide a signed statement that staff will have access to the key in order to access all client's P&I funds upon CCL's request to review the funds. The licensee will send a email with the correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Troy Agard

LICENSING EVALUATOR NAME:

Melissa Spaeth

LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2023

LIC809 (FAS) - (06/04)

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