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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 366425231
Report Date: 10/24/2023
Date Signed: 10/24/2023 11:41:25 AM

Document Has Been Signed on 10/24/2023 11:41 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHITEGATE MANORFACILITY NUMBER:
366425231
ADMINISTRATOR:HANNER, JOHNFACILITY TYPE:
735
ADDRESS:15050 WHITEGATE LANETELEPHONE:
(909) 923-2116
CITY:FONTANASTATE: CAZIP CODE:
92336
CAPACITY: 4CENSUS: 0DATE:
10/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:John Hanner, AdministratorTIME COMPLETED:
11:41 AM
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Licensing Program Analyst, Amber Coleman, (LPA) arrived unannounced to the Whitegate Manor Adult Residential Facility to conduct an Annual Inspection. LPA rang the doorbell and was greeted by Administrator, John Hanner. LPA introduced self and stated purpose of the visit. LPA was granted entry and provided a place to work. Administrator provided LPA on a walk through of the facility's interior and exterior, then provided facility, resident and staff records for review. LPA informed that the facility has four residents in care. All four residents were attending their Adult Day Programs at the time of the visit. The facility is vendorized with the Inland Regional Center at level 2. LPA conducted a general overall inspection, which included, but was not limited to, the following:

Physical Plant: The facility is licensed for four, (4) ambulatory adults; operating at the capacity approved by Community Care Licensing (CCL). Pathways were free of obstruction and clutter. The facility is maintained at a comfortable temperature for the season. LPA inspected resident bedrooms and found that each room contained all required furniture such as: mattresses, appropriate linens, night stands, adequate storage and sufficient lighting. LPA also observed additional lighting throughout the facility in various nightlights plugged in hallways and bathrooms. LPA inspected resident and staff bathrooms. Each bathroom included sufficient lighting, hand hygiene materials and operational appliances. LPA tested the temperature of the water from the bathroom and kitchen faucets, which was observed within regulatory limits. The facility is equipped with operational smoke detectors and carbon monoxide alarms. Administrator reports disaster drills are conducted on a monthly basis. The facility's last fire drill was conducted on 9/10/23. Posters such as; resident personal rights, letusknow, licensing forms, activities calendar and disaster plans were posted in prominent areas. LPA observed that all cleaning supplies, toxins, sharps, medications and other dangerous items were secure and kept inaccessible to residents in care. LPA also observed that staff, residents and facility files are also maintained in a secure location. Emergency first aid kits, PPE and infection control supplies were observed in the kitchen and readily available to those who may need it.

Please see LIC809-C
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE: DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/24/2023
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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WHITEGATE MANOR
FACILITY NUMBER: 366425231
VISIT DATE: 10/24/2023
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Food Service: Non-perishable and perishable food supply observed is sufficient for number of residents in care. The facility maintains 2 refrigerators and 2 freezers.Facility offers its resident a variety of food items. LPA observed a posted monthly food menu Dishes, cups, and utensils were observed properly stored and in adequate amounts. Emergency food supplies and additional water supply were also observed.
Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week. LPA confirmed all current staff members have annual training verifications as regulated. The also facility provides staff rooms for staff who live on facility grounds.
Record Review: LPA reviewed and confirmed that all 4 resident files contained up to date admission agreements, physician reports, and needs and services plans. LPA also reviewed and confirmed two of the staff files for First Aid/CPR certification and health screenings. There were 2 fire extinguishers observed at the facility. Both were fully charged and last inspected March 2023 .Overall, the facility is clean, maintained in good repair, and operating in safe conditions for residents in care.

Based on observations, interviews and record reviews no deficiencies will be cited per Title 22, California Code of Regulations. A copy of this report was read/reviewed with Facility Representative; signature acknowledges understanding and receipt of report and attachments.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Amber Coleman
LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2023
LIC809 (FAS) - (06/04)
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