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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336412337
Report Date: 01/17/2025
Date Signed: 01/17/2025 01:46:44 PM

Document Has Been Signed on 01/17/2025 01:46 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHITE HOME, THEFACILITY NUMBER:
336412337
ADMINISTRATOR/
DIRECTOR:		DEBORAH STANGELFACILITY TYPE:
735
ADDRESS:26245 WHITE AVETELEPHONE:
(951) 325-8536
CITY:HEMETSTATE: CAZIP CODE:
92548
CAPACITY: 4CENSUS: 4DATE:
01/17/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:05 PM
MET WITH:Frank DeAguilarTIME VISIT/
INSPECTION COMPLETED:
01:55 PM
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Licensing Program Analysts (LPAs) Abdoulaye Zerbo and Venus Mixson conducted an unannounced visit for a required annual inspection. The LPAs were greeted by Administrator Frank DeAguilar, notified him of the purpose for the visit and were allowed to enter the facility to conduct the inspection.

Facility Overview: The facility is a single story building with four (4) residents bedrooms, three(3) bathrooms, Two(2) common areas, an office and a kitchen area. There is no gated pool and there are no firearms on the premises.

Infection Control: LPAs observed that hygiene and cleaning supplies were available for regular facility maintenance. The facility’s infection control plan was reviewed and found to meet department requirements.

Physical Plant: The physical plant, including floors, windows, and doors, was clean and well maintained. Fixtures and furniture were in good repair. Laundry equipment was in good working condition. Sharp and dangerous objects were securely locked in the kitchen inaccessible to residents. The smoke detector and carbon monoxide detector were operational. LPAs observed fire extinguishers to be in compliance with the department requirements and with an expiration date of October 25, 2025. The water temperature was tested within regulations.

Continued 809-C......


SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2025
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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WHITE HOME, THE
FACILITY NUMBER: 336412337
VISIT DATE: 01/17/2025
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Care & Supervision/Administration: Adequate staff were present to supervise clients during the visit. The administrator holds a current administrator’s certificate with expiration date of February 21, 2025 and a CPR certification with the expiration date of September 5th, 2026

Record Review and Resident/Staff Files: LPAs reviewed files for four(4) staff members, confirming criminal clearances, updated training, and CPR/First Aid certification. Four (4) residents' files were reviewed and contained all required documentation. LPAs observed first aid kit to be locked and inaccessible to the residents in care. The residents and staff files were kept in the office and inaccessible to unauthorized individuals


Health-Related Services/Incidental Medical Services: All residents' medications were securely locked in a cabinet and located in the office. LPAs reviewed medications for four residents, confirming that all medications were listed and accounted for.

Disaster Preparedness: LPAs reviewed the facility’s emergency and disaster plan, including documentation of the last fire drill conducted on 12-24-2024, which met department requirements. All facility exits were clear of obstructions.


No deficiencies were cited during the visit. An exit interview was conducted, during which this report was reviewed, and a copy was provided to administrator Frank DeAguilar.
SUPERVISORS NAME: Rikesha Stamps
LICENSING EVALUATOR NAME: Abdoulaye Zerbo
LICENSING EVALUATOR SIGNATURE:

DATE: 01/17/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/17/2025
LIC809 (FAS) - (06/04)
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