405850232-2-2-2022-29-AS-DCHZ-CBA3BD-20220202170609

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405850232
Report Date: 02/02/2022
Date Signed: 02/02/2022 05:06:41 PM

Document Has Been Signed on 02/02/2022 05:06 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	WHITE HOUSE, THE		FACILITY NUMBER:	405850232
ADMINISTRATOR:	WHITE, ROBERT		FACILITY TYPE:	735
ADDRESS:	2500 STARLING DR		TELEPHONE:	(805) 674-7787
CITY:	PASO ROBLES	STATE: CA	ZIP CODE:	93446
CAPACITY: 6		CENSUS: 0	DATE:	02/02/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:52 AM
MET WITH:	Robert White, Applicant, and Tanya White, Staff		TIME COMPLETED:	03:15 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) Darlene Chavez conducted an announced pre-licensing visit. LPA met with applicant Rob White and staff Tanya White. Applicant took LPA on a tour of the facility and the following is noted: Medications: There is a locked box in the office, located off the kitchen, to secure resident medications. Physical Plant: The facility is a 4-bedroom, 2.5 bathroom with a kitchen, dinette, office, living room, laundry room, and garage. Facility is clean, sanitary and in good repair. Indoor and outdoor passageways, open porches, and other areas of potential hazard are free of obstructions. The facility does not have any pools or bodies of water. The facility does not store or allow firearms or ammunition to be stored at the facility. Any dangerous products/tools will be stored in the locked garage. Soaps, detergents, and cleaning supplies are kept in a locked cupboard in the laundry room. All window screens are clean and in good repair. Facility temperature is between 68-85 F degrees. Fireplace has a secured screen making it inaccessible to clients in care. The facility does not have any areas that would require hand railings at this time. Smoke and carbon monoxide detectors were tested and operating properly throughout the facility. The two outdoor side gates need self-closing mechanisms added and the side gate by the garage needs a handle and lock on the interior toward backyard. Applicant will install, take a video, and send to LPA. Bedrooms: The facility has four resident bedrooms, two with double occupancy and two with single occupancy. Bedrooms have beds for each resident with mattress, mattress pads, bed springs and pillows which are clean and in good repair. Mattresses and pillows are flame-retardant. The rooms have dressers and closet space for residents. The rooms are furnished with chairs and proper lighting and/or lamps in each room for clients. Continued on 809-C.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WHITE HOUSE, THE	FACILITY NUMBER: 405850232
	VISIT DATE: 02/02/2022

NARRATIVE

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Bathrooms: The facility has 2.5 bathrooms, all for residents. Two bathrooms have a toilet, sink, and showers/tubs. One bathroom has a toilet and sink. Bathrooms are located near resident rooms. Water temperatures in bathroom #1 was 120 F, bathroom #2 at 117.8 F, bathroom #3 at 118.1 F, and the laundry room sink temperature at 120 F.
There are night-lights in the hallways outside non-private bathrooms.
Supplies: The facility has a minimal supply of resident personal hygiene supplies, clean linens, towels and wash clothes. Applicant states they will be transferring these items from the old White House. Applicant will take a photo of the items once they are transferred into the new facility and send photo to LPA.
Food Service: The dinette is next to the kitchen. The refrigerator has not been installed yet. Applicant states they will be transferring the refrigerator from the old White House facility to the facility listed above. Applicant will take a photo of the refrigerator and freezer temperatures and email/text to LPA. A seven-day supply of non-perishable food is present. The facility currently does not have tableware, table, dishes, pots/pans and utensils. Applicant states they will be transferred from the former White House facility. Applicant will take photos of their current supply and send to LPA. There are sufficient amounts of equipment for the storage, preparation and service of food. All equipment are clean and well maintained. All kitchen, food storage, and preparation areas are clean. The kitchen sink’s water temperature was recorded at 116.3 F degrees.
Records: The facility has confidential storage for personnel and resident records, they will be kept in a locked box in the office which also has a locked door.
Administration: The facility has emergency plan and phone numbers posted, Residents rights, Rights of person with disability's, and Licensing Complaint Poster is posted in a prominent place at the facility. The facility’s visiting policy has not been posted. Applicant will post on the front door, take a photo, and send to LPA. The facility has space for resident council meetings and resident council postings, if needed.
Activities: The facility has three boxes of games, books, and videos for residents. There is an outdoor space with a shaded area and furnished for outdoor use. There is at least one common room available to residents for visitors.
Miscellaneous: The facility has a first aid kit at the former facility. Applicant will send photos of the first aid kit and contents to LPA. There is a space and equipment for laundry. The facility does not have an operating telephone available at this time. Applicant will install a phone, test it, take a video doing so, and send to LPA. Applicant has stated that the phone number for residents to use is 805-238-4947. Facility has emergency lighting and supplies to include flashlights with batteries. Vehicle used to transport residents is in safe operating condition, the vehicle is a 2016 Dodge Van with current registration and insurance to safely transport residents.

Exit interview conducted and report emailed to applicant.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Darlene Chavez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022

LIC809 (FAS) - (06/04)

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