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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004223
Report Date: 08/09/2024
Date Signed: 08/09/2024 01:28:15 PM

Document Has Been Signed on 08/09/2024 01:28 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:
08/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:09 AM
MET WITH:Zenaida Abriam, LicenseeTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 8/9/24, at 10:09am, Licensing Program Analyst (LPA) Arvin Villanueva, arrived unannounced at this facility to conduct their required annual inspection visit. When LPA initially arrived, there was no one to answer the door. LPA telephoned Licensee Zenaida Abriam to inform the purpose of the visit. At 10:41am, Licensee arrived at the facility. During this visit, clients in care were out in the community and no staff on duty present.

At 10:45am, LPA inspected the physical plant. The facility is a one-story home located in a residential neighborhood. Front yard and backyard were observed to be clean and free of obstruction. There is a covered patio at the back equipped with outdoor furniture for clients use. During the inspection of the back yard, LPA observed two window screens needing repair as evidenced by the observation of small holes. Also the side gate by the garage was observed to be dragging at the bottom when LPA tried to swing it open. Technical advisory was provided to Licensee to make necessary repairs. No bodies of water was observed at this time.

Four client bedrooms were inspected and observed to be clean and large enough space to accommodate client belongings. Two bathrooms were inspected and observed to be in good repair and containing non-skid mats and close lid garbage. The kitchen was inspected and observed to be sanitized. Food supplies were stored properly. Facility maintains an adequate amount of food supply with 2-day perishables and 7-day nonperishables. Smoke detectors and carbon monoxide monitor were observed and tested and were found to be operable during this visit. Sharps, toxins and medications were observed to be locked and inaccessible to clients. Facility was observed to have adequate supply of linens for clients. Fire extinguisher was observed at the dining area and last serviced on 4/19/24. Room temperature was at 71*F and hot water temperature was at 105*F in both bathrooms inspected. Fireplace was observed to be screened.


SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE: DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/09/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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
VISIT DATE: 08/09/2024
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LPA reviewed 4 of 4 resident records and technical assistance was provided to Licensee to ensure to keep required documents in the facility available for review upon request. LPA review and counted with Licensee 2 of 4 residents' P&I money and found to be accurate. LPA reviewed 2 of 4 residents' medications and found to be in compliance at this time. LPA reviewed 4 personnel records and records were found to be in compliance at this time with current 1st Aid/CPR certificates and DSP 1 and 2 certificates. Facility conducts monthly emergency drills with last drill was conducted on 7/10/24.

LPA requested copies of the following documents to be emailed: current Liability Insurance Certificate, Surety Bond, LIC500, LIC308 and LIC610D.

Based on today's inspection Per the California Code of Regulations, Title 22, Division 6, Chapter 6, no deficiencies were observed or cited. Exit interview held with Zenaida Abriam, and copy of report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Arvin Villanueva
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2024
LIC809 (FAS) - (06/04)
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