365530138-10-4-2023-56-AS-MECA-CWAM93-20231004092404

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 365530138
Report Date: 10/04/2023
Date Signed: 10/04/2023 09:24:14 AM

Document Has Been Signed on 10/04/2023 09:24 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
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME:	WHITE HOUSE, THE		FACILITY NUMBER:	365530138
ADMINISTRATOR:	BICKHAM, EDDIE		FACILITY TYPE:	735
ADDRESS:	15363 PATTON ST		TELEPHONE:	(310) 435-4163
CITY:	VICTORVILLE	STATE: CA	ZIP CODE:	92394
CAPACITY: 4		CENSUS: 0	DATE:	10/04/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:18 AM
MET WITH:	Eddie Bickham-Licensee		TIME COMPLETED:	09:30 AM

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) Michelle Echeverria conducted an announced visit to perform a Pre-licensing Inspection. LPA met with Licensee, Eddie Bickham. The fire clearance was approved on 5/23/2023 for four (4) ambulatory clients. The facility has four (4) bedrooms, three (3) bathrooms, one (1) staff office, kitchen, dining room, living room with fireplace, laundry room, backyard, and attached garage. LPA toured the interior and exterior areas of the facility. The following were inspected: Client Bedrooms: All bedrooms have the required bedding and furniture, such as, clean mattresses/linen, nightstands, dressers, chairs, and lighting. Client Bathrooms: The bathroom appliances were operating in safe and sanitary condition. Kitchen and Dining Areas: Utensils and dishware are in good repair and ready for client use. Kitchen appliances and counter top were free of debris and in good repair. The water temperature was measured at 105.8 degrees F. The refrigerator was measured at 39 degrees F and the freezer was measured at 0 degrees F. There was a locked and secured cabinet where medication and sharps will be stored. There was also non-perishable food inside kitchen cabinets and perishable food inside the refrigerator/freezer. Staff Office: There is a safely locked and secured filing cabinet where clients and staff files are going to be stored. Common Sitting Areas: There is adequate seating in the common areas. The facility has a supply of activities for the clients.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WHITE HOUSE, THE	FACILITY NUMBER: 365530138
	VISIT DATE: 10/04/2023

NARRATIVE

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Laundry Room/ Garage: The laundry room is near the entry to the garage. The chemicals and laundry soap were safely locked inside a cabinet..

Linens and Hygiene Supplies: An adequate supply of linens was available.

Backyard: There are no bodies of water in the backyard. All passageways were free from obstruction.

Fire extinguisher, carbon monoxide, firearms: There was (1) charged fire extinguisher in the facility. LPA observed operating smoke detectors and carbon monoxide alarms. The home does not have any firearms and ammunition.

Postings: LPA observed required postings including the visitation policies, emergency/disaster plans, complaint procedures, and personal rights.

First aid and telephone: The facility was equipped with a complete first aid kit and emergency kits. The facility has a functioning land line with telephone for clients use.

The facility was evaluated in accordance with the California Code of Regulations (CCR), Title 22. Based on the observations and evaluation of the facility this date, the facility is ready for licensure. Comp III was completed with Licensee.

Licensee will be notified once facility is licensed.

An exit interview was conducted, and this report was discussed and provided to Licensee, Eddie Bickham.

SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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