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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412337
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:48:13 AM

Document Has Been Signed on 02/03/2023 10:48 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:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:ADMINISTRATOR, ASSISTANT SANDRA ASCENCIO.TIME COMPLETED:
10:57 AM
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On February 3, 2023, Licensing Program Analyst (LPA), Venus Mixson arrived at the above facility for an unannounced required annual with emphasis on infection control.

LPA Mixson met Assistant Administrator introduced self and stated the purpose of the visit.

Present in the facility were two caregivers, and no residents, due to all four residents being at the day program. There are currently no positive cases of COVID-19 within the facility. All residents and staff are fully vaccinated and boosted.

LPA Mixson toured the facility with Assistant Administrator and made observations pertaining to the facility's infection control measures. LPA Mixson observed sufficient hand hygiene supplies, sufficient cleaning and disinfecting provisions, and the proper use of face coverings.

The facility has a designated infection control lead person who has been tasked with tracking all COVID-19 cases and/or suspected cases, ensuring PPE supplies are maintained, and cleaning and disinfection provisions are in adequate quantities.

LPA Mixson later discussed infection control practices and procedures with Assistant Administrator.

An exit interview was conducted and a copy of this report was given to Assistant Administrator.
SUPERVISORS NAME: Jazmond D Harris
LICENSING EVALUATOR NAME: Venus Mixson
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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