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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004223
Report Date: 03/22/2024
Date Signed: 03/22/2024 01:21:27 PM

Document Has Been Signed on 03/22/2024 01:21 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:KATHY ABRIAM RHYMESFACILITY TYPE:
735
ADDRESS:9460 WHITE HORSE WAYTELEPHONE:
(916) 897-8891
CITY:ELK GROVESTATE: CAZIP CODE:
95624
CAPACITY: 4CENSUS: DATE:
03/22/2024
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Zenaida AbriamTIME COMPLETED:
01:30 PM
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On 3/22/24, at 9:40am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived to this facility to conduct case management visit to obtain documents relating to Resident_1 (R1). When LPA initially arrived, there was no one to answer the door. LPA called the Administrator Kathy Abriam Ryhmes to inform of the visit. LPA was informed that the administrator is not available to meet at this time but the licensee will arrived shortly. LPA waited for Licensee Zenaida Abriam to arrived.

LPA obtained copy of the following documents as it relates to R1: physician communication logs, behavioral plan reports, facility menu, Individual Program Plan (IPP) reports, Individual Services Plan (ISP) reports, and care notes.

No deficiencies were cited during today's visit.

An exit interview was held, and report was provided to Zenaida Abriam.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 03/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/22/2024
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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