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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530138
Report Date: 10/07/2024
Date Signed: 10/07/2024 01:44:10 PM

Document Has Been Signed on 10/07/2024 01:44 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
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHITE HOUSE, THEFACILITY NUMBER:
365530138
ADMINISTRATOR/
DIRECTOR:		BICKHAM, EDDIEFACILITY TYPE:
735
ADDRESS:15363 PATTON STTELEPHONE:
(310) 435-4163
CITY:VICTORVILLESTATE: CAZIP CODE:
92394
CAPACITY: 4CENSUS: 2DATE:
10/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Administrator, Eddie BickhamTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
NARRATIVE
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On 10/07/2024 at 10:21 AM, Licensing Program Analysts (LPAs) Renese Howell-Small and Magda Malcore conducted an unannounced visit to the facility to conduct the required comprehensive annual inspection to the facility. LPA’s Small and Malcore were greeted by a staff and gained access to the residence. Licensee/Administrator Eddie Bickham was contacted and informed of the visit. LPA’s Small and Malcore explained the purpose of the visit to Licensee/Administrator Eddie Bickham.

The facility has four (4) bedrooms, three (3) bathrooms, kitchen, dining room, living room, attached garage, and backyard. The facility is vendorized by Inland Regional Center (IRC). LPA’s Small and Malcore completed a walk through of the facility, review of records, and medications audit.



Physical Plant: The facility is operating in the capacity approved by Community Care Licensing Division (CCLD). LPAs Small and Malcore observed one (1) client during the visit. One (1) client is out in the community. There are no obstructions to indoor and outdoor passageways. The facility is maintained at a comfortable temperature of 75 degrees Fahrenheit. LPA’s Small and Malcore inspected client bedrooms; they are equipped with required furniture such as: mattresses, nightstands, storage space, chairs, and sufficient lighting. LPA’s Small and Malcore inspected client bathrooms; bathrooms were clean, and appliances were found functional. Water temperatures tested at 112 degrees Fahrenheit. The facility is equipped with operational smoke detectors, carbon monoxide detectors, a charged fire extinguisher, and first aid kit with first aid book.

Posters such as; the personal rights, CCLD complaint poster, labor laws, and emergency disaster plan were posted in a common area. Client medications were kept in secure cabinets inaccessible to clients. LPA’s Small and Malcore observed night lights in the hallway leading to clients' shared bathrooms. The facility had emergency kits, emergency food and water. There are no firearms and ammunition in the facility.
SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE: DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/07/2024
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 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SAN BERNARDINO ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WHITE HOUSE, THE
FACILITY NUMBER: 365530138
VISIT DATE: 10/07/2024
NARRATIVE
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 *** Continuation in LIC809C ***

Yards/Outside: One shaded patio, one (1)side gate with self-latching handle on the right side of the house that leads into the backyard, attached two (2) car garage observed. All outdoor pathways were free of obstructions.

Food Service: LPA’s Small and Malcore observed two (2) day(s) supply of perishable food and seven (7) day(s) supply of non-perishables food and snacks. Dishes, cups, and utensils were stored properly.


Care & Supervision: Facility has sufficient care staff for coverage 24 hours a day, 7 days a week.

Record Review: LPA’s Small and Malcore reviewed two (2) client files for admission agreements, medical assessments/physician reports and Individual Program Plan (IPP). LPA’s Small and Malcore observed files reviewed were missing Resident #2's (R2) Physician's Report. A deficiency will be issued. LPA’s Small and Malcore also reviewed staff and administrator's file for First Aid/CPR certification, criminal record clearance, trainings, and health screenings with tuberculosis (TB) test result. LPA's observed one staff file to be missing a copy of the CPR certification. A Technical Assistance will be given.

LPA Small and Malcore audited two (2) clients’ medications and one (1) issue was observed. Resident #1's (R1) was not given medication on 10/06/24. A deficiency will be issued. LPA’s Small and Malcore audited two (2) client's Personal and Incidental (P&I) and no issues were observed.

Two (2) deficiencies were cited during this visit and a Technical Assistance. An exit interview was conducted where this report LIC809, LIC809C, (LIC809D), Technical Assistance and (Appeal Rights) were discussed, and copies were provided to Licensee/Administrator Eddie Bickham.

SUPERVISORS NAME: Karen Clemons
LICENSING EVALUATOR NAME: Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:

DATE: 10/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 10/07/2024 01:44 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 10/07/2024 at 01:08 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WHITE HOUSE, THE
FACILITY NUMBER: 365530138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
80075(b)(5)(B)
Health-Related Services
(b) Clients shall be assisted as needed with self-administration of prescription and nonprescription medications. (5) If the client's physician has stated in writing that the client is unable to determine his/her own need for nonprescription PRN medication, but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the client with self-administration, provided all of the following requirements are met: (B) Once ordered by the physician the medication is given according to the physician's directions.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above by not ensuring that staff give medication according to the physician's orders which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/08/2024
Plan of Correction
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Administrator ageed to train staff in ensuring medication is logged and given according to the physician's orders and will submit proof of training by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/07/2024 01:44 PM - It Cannot Be Edited


Created By: Renese Howell-Small On 10/07/2024 at 01:08 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
, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507

FACILITY NAME: WHITE HOUSE, THE
FACILITY NUMBER: 365530138

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
80069(c)
Client Medical Assessments
(c) The medical assessment shall include the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review , the licensee did not comply with the section cited above by not ensuring that resident files are complete with Physician's report which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/14/2024
Plan of Correction
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Administrator will submit current Physician's report by Plan of Correction (POC) due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Karen Clemons
LICENSING EVALUATOR NAME:Renese Howell-Small
LICENSING EVALUATOR SIGNATURE:
DATE: 10/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/07/2024


LIC809 (FAS) - (06/04)
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