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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850232
Report Date: 01/07/2025
Date Signed: 01/07/2025 02:47:15 PM

Document Has Been Signed on 01/07/2025 02:47 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/
DIRECTOR:		TONYA L WHITEFACILITY TYPE:
735
ADDRESS:2500 STARLING DRTELEPHONE:
(805) 674-7787
CITY:PASO ROBLESSTATE: CAZIP CODE:
93446
CAPACITY: 6CENSUS: 6DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:01 AM
MET WITH:Licensee, Rob WhiteTIME VISIT/
INSPECTION COMPLETED:
11:52 AM
NARRATIVE
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 At 8:00am on 01/07/2025, Licensing Program Analyst (LPA) Jeffries arrived unannounced to the facility to conduct the facility annual inspection. LPA met with Licensee Rob White and Administrator Tonya White> LPA 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 70* (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 living room. 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 conducted a staff and client record review and did not find any violations or citations during the facility tour and records review. LPA noted that during the physical tour of the facility LPA noted to licensee that floors were not free of debris and were not clean. LPA issued a Type B citation (85095.5(a)(2)(A). Additionally, LPA noted during the physical inspection of the facility that the laundry room was open with chemicals accessible to clients in care. LPA cited regulations 80087(g).

Licensee, Administrator and LPA conducted a full review and the annual care tools modules, LPA noted that two citations were issued as noted above during the full care tool modules review.

Exit interview, report read, appeal rights, and report provided
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Mark Jeffries
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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Document Has Been Signed on 01/07/2025 02:47 PM - It Cannot Be Edited


Created By: Mark Jeffries On 01/07/2025 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
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: WHITE HOUSE, THE
FACILITY NUMBER: 405850232

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
85095.5(a)(2)(A)
Infection Control Requirements
(a) A licensee shall ensure that infection control practices are maintained as follows: (2) Environmental cleaning and disinfection activities shall be performed following the manufacturers' instructions for proper use of the cleaning and disinfecting products.  These activities shall be completed, at a minimum, as follows:  (A) Surfaces such as floors, chairs, toilets, sinks, counters and tabletops shall be cleaned and disinfected on a regular basis to ensure they are safe and sanitary.  These surfaces shall also be disinfected when these surfaces are contaminated and visibly soiled with blood or body fluids or other potentially infectious material. 

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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Type B
Section Cited
CCR
80087(a)
Building and Grounds
(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on [(observation) (interview) (record review)], the licensee did not comply with the section cited above in [count] out of [total count] [(objects) (persons)] [identifiers] which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date:
Plan of Correction
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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:Kelly Burley
LICENSING EVALUATOR NAME:Mark Jeffries
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2025


LIC809 (FAS) - (06/04)
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