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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850232
Report Date: 01/17/2024
Date Signed: 01/17/2024 01:11:19 PM

Document Has Been Signed on 01/17/2024 01:11 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, THEFACILITY NUMBER:
405850232
ADMINISTRATOR:HOBSON, NANCYFACILITY TYPE:
735
ADDRESS:2500 STARLING DRTELEPHONE:
(805) 674-7787
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
01/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Rob White - Licensee TIME COMPLETED:
01:18 PM
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At 9:30am on 01/17/2024, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the full annual facility inspection. LPA met with Licensee, Robert White, announced who he is and the reason for the visit.

The facility is a 4 bedroom, 2.5 bathroom with a kitchen, dinette, office, living room, laundry room, and garage. There is a large back yard with seating and shade for visitors and clients. LPA conducted a full physical tour of the facility. LPA observed bedrooms to be properly furnished, with appropriate amounts and types of linin and bedding. LPA noted that all bathrooms have liquid soap and paper towels, all appliances are in working condition and the water temperature was measured within regulation range of 105* -120* (f). LPA noted that the facility temperature indicated 73* (f) when the current outside temperature was 51*(f). LPA noted that there are working smoke detectors located throughout the facility and a working carbon monoxide detector in the facility hallway. LPA noted that the fire extinguisher is located at the entrance to the living room and was tagged and tested in the green. LPA noted that the medications are locked in the cabinet safe in the kitchen. LPA observed at least two days of non perishable foods and at least seven days of perishable foods for at least 6 clients and staff. LPA noted that the facility has a first aide kit that has all minimum items required by regulations. LPA noted that the facility was clean and in good repair, all hallways and exits were free and clear of obstacles a debris. LPA conducted a sample review of clients centrally stored medications records (CSMR) and medication audit. LPA conducted a staff and client record review and did not find any violations or citations during the facility tour and records review.

Licensee and LPA conducted a full review and the annual care tools modules, LPA noted that there were not technical, violations, or citations issued as a result of the full care tool modules review. LPA noted that there were not technical, violations, or citations during this annual facility inspection.

Exit interview, report read, and report provided.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 01/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/17/2024
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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