<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004223
Report Date: 05/10/2022
Date Signed: 05/20/2022 02:44:10 PM

Document Has Been Signed on 05/20/2022 02:44 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
CCLD Regional Office, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833
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: 4DATE:
05/10/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
12:26 PM
MET WITH:Zenaida AbriamTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Jamie Ivey Canady and Licensing Program Manager (LPM) Stephenie Doub arrived to the facility unannounced. LPA rang the doorbell multiple times, before one of the clients opened the door and let the LPAs in the facility. Upon entry, LPA and LPM observed three clients in the facilty. LPA Ivey Canady and LPM Doub called for staff but there was no answer. LPAs were in the facility for approximately 5 minutes before staff was alerted of LPAs arrival. LPA Ivey Canady explained the reason for the visit and requested staff call licensee Zenaida Abriam who arrived for the visit within 20 minutes.

LPA toured the facility with Licensee. In the kitchen, LPA observed scissors unsecured in the sink as well as medications unlocked in the pantry closet. Upon further investigation, LPM observed cleaning supplies to be unsecured in the facility far back bathroom. It was observed that the cabinet locks were broken. Three of three clients require supervision when near hazardous materials and sharp objects.

LPA also cleared deficiency cited 3/24/2022 and provided letter of deficiency cleared to Administrator.

Per California Code of Regulations, Title 22 Division 6, Chapter 8, deficiencies were cited on the attached LIC 809-D. Failure to correct the deficiency may result in civil penalties. Appeal rights were provided. An exit interview was conducted, and a copy of the report was provided to Administrator.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE: DATE: 05/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/10/2022
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 2
Document Has Been Signed on 05/20/2022 02:44 PM - It Cannot Be Edited


Created By: Jamie Ivey-Canady On 05/10/2022 at 12:42 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
, 2525 NATOMAS PARK DR. STE.270
SACRAMENTO, CA 95833

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/10/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/10/2022
Section Cited
CCR
80087(a)(1)(g)

1
2
3
4
5
6
7
800879(a)The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, ...(g)Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily..
This regulation was not met as evidence by:
1
2
3
4
5
6
7
LPA and LPM observed sharp objects were secured during visit. Licensee stated she will train all staff and a copy of training will be provided by 5/11/2022.
8
9
10
11
12
13
14
The licensee did ensure that the facilty was safe for clients in care. Based on observation of the facility; Scissors and medication were unsecured which pose an immediate health and safety risk to clients in care..
8
9
10
11
12
13
14
Type A
05/10/2022
Section Cited
CCR80075(k)(1)

1
2
3
4
5
6
7
80075(k)(1)Health Related Services (k) The following requirements shall apply to medications which are centrally stored:(1) Medication shall be kept in a safe and locked place that is not accessible to persons...This is evidenced by;
1
2
3
4
5
6
7
Medications were secured. Licensee stated she will provide training to staff and provide a copy of training will be provided by 5/11/2022.
8
9
10
11
12
13
14
The licensee did not ensure that medication were kept locked and inaccessible to persons. Based on observation in the facility, medications were unsecured. This poses an immediate risk to clients in care.
8
9
10
11
12
13
14
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:Jamie Ivey-Canady
LICENSING EVALUATOR SIGNATURE:
DATE: 05/10/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/10/2022


LIC809 (FAS) - (06/04)
Page: 2 of 2