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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850232
Report Date: 12/17/2022
Date Signed: 12/19/2022 05:52:08 AM

Document Has Been Signed on 12/19/2022 05:52 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:WHITE HOUSE, THEFACILITY NUMBER:
405850232
ADMINISTRATOR:HOBSON, NANCYFACILITY TYPE:
735
ADDRESS:2500 STARLING DRTELEPHONE:
(805) 674-7787
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
12/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:14 AM
MET WITH:Robert White/LicenseeTIME COMPLETED:
10:15 AM
NARRATIVE
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 At 8:08am on 12/17/2022, Licensing Program Analyst (LPA) Jeffries arrived unannounced at the facility to conduct the an infection control annual inspection. LPA met with Licensee Robert White and announced who he was and the reason for the visit.

Licensee and LPA conducted a cursory tour of the facility. LPA noted that all fire alarms and carbon monoxide detectors were functioning properly. LPA noted that the ambient temperature of the facility was 73*f, as the temperature outside was 36*f.. LPA noted that there were at least 2 days of perishable and seven days of non-perishable foods on hand at the facility, LPA noted that all the bathrooms had liquid soap and hand sanitizer stocked in the bathrooms. LPA did not observe any hazards or issued that would warrant a citation during the cursory tour of this facility and no citations were issued as a result of the cursory tour.

At 9:18am License and LPA conducted the infection control module of the annual inspection. LPA noted that they did not discover any issued in the annual infection control porting of the annual visit and there were no citations issued at this time.

Exit interview, report singed, and report emailed.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 12/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/17/2022
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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