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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609647
Report Date: 12/12/2024
Date Signed: 12/12/2024 04:01:40 PM

Document Has Been Signed on 12/12/2024 04:01 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 LLCFACILITY NUMBER:
197609647
ADMINISTRATOR/
DIRECTOR:		WHITE, EDMONDFACILITY TYPE:
735
ADDRESS:4054 TOURNAMENT DRTELEPHONE:
(661) 526-3088
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 4DATE:
12/12/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Antonia WhiteTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Melissa Spaeth conducted an unannounced annual visit on 12/12/2024. LPA was greeted by the caregiver. The caregiver spoke to the Administrator via phone call. 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 10:00 am until 10:45 am. LPA observed the following:

Common areas – The living room and family room contained comfortable seating. The dining room contained a dining room table and chairs.

Hallway closet- The kitchen closet was locked and contained the clients’ files, clients' medication, knives, PPE supplies, and first aid kit.

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 and additional PPE supplies.



Backyard – There is a shaded seating area in the backyard. The gate leading from the backyard to the front yard was not locked.
Continued on 909
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/12/2024
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
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: 12/12/2024
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Client Rooms - LPA observed four client rooms which contained bed, linens, night stand, lamp, closet and chest of drawers. All rooms were neat and clean.

Staff Room - The room was locked

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



Bathrooms – LPA observed the bathrooms contained hand soap, paper towels, and covered trash cans.

Water Temperature - The water temperature was tested at 10:35 am and was 116.3 degrees F.

Smoke/Carbon Monoxide Detectors – The smoke and carbon monoxide detectors were tested at 10:45 am and were operable.

Client Records - LPA reviewed the records at 10:50 am until 11:40 am.

Staff Records LPa reviewed the staff records at 11:40 am until 12:20 pm.

Personal and Incidental (P&I) funds - LPA reviewed the clients' P&I funds at 12:20 pm until 12:25 pm

Client Medications - LPA reviewed the records at 12:25 pm until 12:50 pm.

There are no deficiencies to report at this time.

Exit interview conducted and a copy of the report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 12/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2024
LIC809 (FAS) - (06/04)
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