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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004223
Report Date: 09/11/2024
Date Signed: 09/11/2024 04:09:41 PM

Document Has Been Signed on 09/11/2024 04:09 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
SACRAMENTO SOUTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:WHITE HORSE HOME, INC.FACILITY NUMBER:
347004223
ADMINISTRATOR/
DIRECTOR:		KATHY ABRIAM RHYMESFACILITY TYPE:
735
ADDRESS:9460 WHITE HORSE WAYTELEPHONE:
(916) 897-8891
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: 4DATE:
09/11/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:45 PM
MET WITH:Zenaida Abriam, LicenseeTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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On 9/11/24. at 2:45pm, Licensing Program Analyst (LPA) Arvin Villanueva arrived at this facility unannounced to conduct a case management visit. LPA met with the Facility Manager, Rona Pataw, and explained the purpose of the visit. The Licensee was informed of the visit and arrived shortly after. During this visit, present were 4 clients in care with 2 staff on duty.

This visit is to cite deficiencies as noted during a Title 17 Monitoring Review conducted on 9/3/24 by Alta California Regional Center (ACRC) representatives. The Department was made aware that inadequacies were found substantiated during a medication review. ACRC representatives noted that some PRN medications belonging to 3 of 4 clients in care were not recorded in their Centrally Stored Medication Records.

Based on interview with Licensee during this visit, the facility currently working on the correction plan noted in the Title 17 Monitoring Review report.

Per California Code of Regulations, Title 22 Division 6, deficiencies are being cited during this visit. If any deficiencies are not corrected by the noted due dates, civil penalties may be assessed.

An interview was held with the Licensee, Zenaida Abriam, and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2024
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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Document Has Been Signed on 09/11/2024 04:09 PM - It Cannot Be Edited


Created By: Arvin Villanueva On 09/11/2024 at 03:24 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827

FACILITY NAME: WHITE HORSE HOME, INC.
FACILITY NUMBER: 347004223

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/11/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
09/18/2024
Section Cited
CCR
80075(k)(7)

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(k) The following requirements shall apply to medications which are centrally stored: (7) The licensee shall ensure the maintenance, for each client, of a record of centrally stored prescription medications which is retained for at least one year and includes the following:
This requirement is not met as evidenced by:
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Licensee to submit a statement of understanding regarding CCR Section 80075 as it relates to maintaing record of centrally stored prescription medications. Statement to be submitted to the Department by POC due date.
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Based on interview and record review, the licensee did not comply with the section cited above. During a Title 17 monitoring review, it was reported that some PRN medications of 3 of 4 clients were not logs in the Centrally Stored Medication Records which poses/posed a potential health, safety or personal rights risk to persons in care.
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The licensee shall continue with implementing the corrective action plan established by Alta California Regional Center.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Stephen Richardson
LICENSING EVALUATOR NAME:Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:
DATE: 09/11/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/11/2024


LIC809 (FAS) - (06/04)
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