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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530138
Report Date: 08/07/2024
Date Signed: 08/07/2024 04:00:49 PM

Document Has Been Signed on 08/07/2024 04:00 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, 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:
08/07/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:22 AM
MET WITH:Eddie Bickham-AdministratorTIME VISIT/
INSPECTION COMPLETED:
04:10 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) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240729153737. LPA met with Administrator, Eddie Bickham.

During today's visit, LPA conducted interviews with residents, staff, obtained and reviewed facility records, and did a walk-through of the facility. LPA found the following issues:
  • Personnel records not available for inspection.
  • Not reporting an unusual incident that threaten the emotional health or safety of a client.
  • Personnel not reporting observations or evidence of violations of any of the personal rights.
  • Personnel making false or misleading statement about any of the services provided by the facility.
These pose an immediate and potential health and safety risk to residents in care. Refer to LIC 809D for deficiencies cited.

An exit interview was conducted where this report LIC809, LIC809D, and appeal rights were discussed with and provided to Administrator, Eddie Bickham.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/07/2024
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 3
Document Has Been Signed on 08/07/2024 04:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/07/2024 at 03:03 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/08/2024
Section Cited
CCR
80065(m)

1
2
3
4
5
6
7
80065(m) Personnel Requirements
(m)All personnel shall be instructed to report observations or evidence of violations of any of the personal rights specified in Section 80072 and/or any of the personal rights provisions of Chapters 3 through 7. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that he will review the regulation cited with personnel and submit proof to LPA via email by POC due date.
8
9
10
11
12
13
14
Based on observations, interviews and record review, the administrator did not comply with the section cited above by making sure that personnel reported observations of violations of personal rights which poses an immediate health, safety and personal risk to persons in care.
8
9
10
11
12
13
14
Type A
08/08/2024
Section Cited
CCR80012(a)

1
2
3
4
5
6
7
80012(a) False Claims
(a) No licensee, officer, or employee of a licensee shall make or disseminate any false or misleading statement regarding the facility or any of the services provided by the facility. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that he will review the regulation cited and submit a statement of understanding to LPA via email by POC due date.
8
9
10
11
12
13
14
Based on observations, interviews and record review, the administrator did not comply with the section cited above by making a false or misleading statement regarding the services provided by the facility which poses an immediate health, safety and personal risk to persons 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 08/07/2024 04:00 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 08/07/2024 at 03:24 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: 08/07/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/16/2024
Section Cited
CCR
80066(c)

1
2
3
4
5
6
7
80066(c) Personnel Records
(c) All personnel records shall be available to the licensing agency to inspect, audit, and copy upon demand during normal business hours. Records may be removed if necessary for copying...requirements: This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that he will have all personnel records available for inspection when licensing is present. Administrator stated that he will submit copy of the missing personnel records to LPA via email by POC due date.
8
9
10
11
12
13
14
Based on observations, interviews and record review, the administrator did not comply with the section cited above by having all personnel records available for inspection which poses a potential health, safety and personal risk to persons in care.
8
9
10
11
12
13
14
Type B
08/16/2024
Section Cited
CCR80061(b)(1)(E)

1
2
3
4
5
6
7
80061(b)(1)(E) Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of...following: (E) Any unusual incident or client absence which threatens the physical or emotional health or safety of any client. This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator stated that he will submit an incident report to licensing for the incident that occurred on 7/27/24 at 2:02pm. Administrator stated that he will review regulation cited and submit a statement of understandin to LPA via email by POC due date.
8
9
10
11
12
13
14
Based on observations, interviews and record review, the administrator did not comply with the section cited above by submitting an incident report on 7/27/24 which poses a potential health, safety and personal risk to persons 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024


LIC809 (FAS) - (06/04)
Page: 3 of 3