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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 365530138
Report Date: 10/03/2024
Date Signed: 10/03/2024 12:17:02 PM

Document Has Been Signed on 10/03/2024 12:17 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: 3DATE:
10/03/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:38 AM
MET WITH:Kevin Johnson-StaffTIME VISIT/
INSPECTION COMPLETED:
12:28 PM
NARRATIVE
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Licensing Program Analyst (LPA) Michelle Echeverria conducted an unannounced visit to this facility to initiate an investigation of complaint number: 56-AS-20240926110610. LPA met with Staff, Kevin Johnson.

During today's visit, LPA conducted interviews with clients, staff, and did a walk-through of the facility. LPA found the following issues:
  • LPA was unable to access facility records since Administrator did not provide access to the staff present.
  • Administrator did not report to the Regional Office of an incident that threatened the safety of the clients.
  • Administrator did not report within 7 days, the occurrence of a separate incident.
  • Knife was previously accessible to clients.


These pose an immediate and potential health and safety risk to clients 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 Staff, Kevin Johnson.
SUPERVISORS NAME: Nedra Brown
LICENSING EVALUATOR NAME: Michelle Echeverria
LICENSING EVALUATOR SIGNATURE: DATE: 10/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/03/2024
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 10/03/2024 12:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/03/2024 at 11:15 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
, 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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
80044(c)

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80044(c) Inspection Authority of the Licensing Agency
(c) The licensing agency shall have the authority to inspect, audit, and copy client or facility records upon demand during normal business hours. Records...and 80070(d). This requirement is not met as evidenced by:
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Administrator stated that he will make sure that facility records are available for inspection when licensing is present and will submit a statement of understanding to LPA via email by POC due date.
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Based on observations and interviews, the administrator did not comply with the section cited above by not having facility records available for inspection which poses a potential health, safety and personal risk to persons in care.
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Type B
10/11/2024
Section Cited
CCR80061(b)(1)(E)

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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:
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Administrator stated that he will hold training with staff on the regulation cited and put a system in place where reports will be sent to the RO for applicable incidents.
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Based on observations, interviews and record review, the administrator did not comply with the section cited above by submitting an incident report for 9/23/24 which poses a potential health, safety and personal risk to persons 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
Page: 2 of 3
Document Has Been Signed on 10/03/2024 12:17 PM - It Cannot Be Edited


Created By: Michelle Echeverria On 10/03/2024 at 11:40 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
, 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: 10/03/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/11/2024
Section Cited
CCR
80061(b)

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80061(b) Reporting Requirements
(b) Upon the occurrence, during the operation of the facility, of any of the events specified in (1) below, a report shall be made to the licensing agency within the agency's next working day during...such event. This requirement is not met as evidenced by:
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Administrator stated that he will include a due date in the system put in place for reporting and will provide a copy to LPA via email by POC due date.
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Based on observations, interviews and record review, the administrator did not comply with the section cited above by submitting an incident report within 7 days of the incident which poses a potential health, safety and personal risk to persons in care.
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Type B
10/11/2024
Section Cited
CCR80087(g)

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80087(g) Buildings and Grounds
(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
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Administrator stated that he will hold a training with staff on the regulation cited and submit proof to LPA via email by POC due date.
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Based on interviews and record review, the administrator did not comply with the section cited above by making a knife accessible to clients which posed a potential health, safety and personal risk to persons 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:Nedra Brown
LICENSING EVALUATOR NAME:Michelle Echeverria
LICENSING EVALUATOR SIGNATURE:
DATE: 10/03/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/03/2024


LIC809 (FAS) - (06/04)
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