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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 347004223
Report Date: 12/30/2022
Date Signed: 12/30/2022 10:34:28 AM

Document Has Been Signed on 12/30/2022 10:34 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
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: 3DATE:
12/30/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Zenida AbriamTIME COMPLETED:
10:35 AM
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Licensing Program Analyst (LPA) Christina Valerio arrived unannounced to the facility to conduct a case management visit. LPA met with Licensee Zenida Abriam and explained the purpose of the visit. During the visit resident's and staff were out on an outing.

LPA requested and reviewed Medication Administrator Records and Centrally Stored Log for all residents in care. Records review revealed the discontinued medication was highlighted to ensure staff were aware. The medication administration record for January will be picked up today from their administrative clerk. Licensee will ensure the discontinued medication is not listed. Licensee stated all staff have been through training for their new medication system.


Based on document review, the facility was placed on sanctions with Alta Regional Center due to non-compliance with Title 17 regulations. The follow were cited on 12/15/22:
  • Levetiraceta 500mg, 1 tab twice daily was discontinued on 11/14/22. The December 2022 MAR identified Levetiraceta 500mg 1 tab twice daily and was incorrectly signed as administered on 12/1/2022 for morning and evening administrations as well as on 12/2/2022 morning administration. The medication was not dispensed by the pharmacy in that bubble pack and the medication was not administered.
  • Zonisamide 100mg, 2 caps at bedtime- The MAR was not signed for the bedtime dose on 12/1/2022.

Based on records review and observations, deficiencies are being cited today on LIC 809 - D. Appeal rights provided. Failure to correct deficiencies may result in civil penalties. An exit interview was held with Licensee Zenida Abriam, and a copy of the report was provided.
SUPERVISORS NAME: Stephen Richardson
LICENSING EVALUATOR NAME: Christina Valerio
LICENSING EVALUATOR SIGNATURE: DATE: 12/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/30/2022
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 12/30/2022 10:34 AM - It Cannot Be Edited


Created By: Christina Valerio On 12/30/2022 at 08:41 AM
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: 12/30/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/20/2023
Section Cited
CCR
80075(k)(7)

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80075Health Related Services (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...This requirement was not met as evidenced by:
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Licensee stated the facility implemented a new medication system. Staff completed training to ensure medication records are reviewed consistenly, discontinued medications will be correctly documents, and signatures will only be obtain for medications given. Licensee to send an in-service sign in sheet to LPA by POC due date.
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Based on observations and records review, the licensee did not ensure client medication records were not maintained, which poses a potential health and safety risk to residents in care.
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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:Christina Valerio
LICENSING EVALUATOR SIGNATURE:
DATE: 12/30/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/30/2022


LIC809 (FAS) - (06/04)
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