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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412337
Report Date: 08/31/2022
Date Signed: 08/31/2022 11:27:17 AM

Document Has Been Signed on 08/31/2022 11:27 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, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHITE HOME, THEFACILITY NUMBER:
336412337
ADMINISTRATOR:DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:26245 WHITE AVETELEPHONE:
(951) 325-8536
CITY:HEMETSTATE: CAZIP CODE:
92548
CAPACITY: 4CENSUS: 4DATE:
08/31/2022
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Sandra Asencio - Assistant House ManagerTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Crystal Colvin conducted an unannounced case management visit for verification of an exclusion order removal. LPA Colvin met with Assistant House Manager Sandra Asencio and explained the purpose of today's visit.

Assistant House Manager Sandra Asencio was provided a copy of the Order to Licensee/Facility of Immediate Exclusion from Facility letter dated 08/31/2022 regarding employee Jeffrey Cisneros. Assistant House Manager Sandra Asencio was advised and understands that employee Jeffrey Cisneros is not to return to this facility or any licensed facility nor have contact with any residents.

Assistant House Manager Sandra Asencio informed LPA that employee Cisneros has never worked at the facility. LPA Colvin obtained a copy of the staff schedule and confirmed that Cisneros is not on schedule.

An exit interview was conducted where this report was discussed and provided to Assistant House Manager Sandra Asencio.
SUPERVISORS NAME: Joel Esquivel
LICENSING EVALUATOR NAME: Crystal Colvin
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2022
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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