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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 336423972
Report Date: 07/03/2025
Date Signed: 07/03/2025 03:26:42 PM

Document Has Been Signed on 07/03/2025 03:26 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
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME:WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCIIFACILITY NUMBER:
336423972
ADMINISTRATOR/
DIRECTOR:		JACQUELYN J. WHITEFACILITY TYPE:
740
ADDRESS:24068 RISTRAS LANETELEPHONE:
(951) 319-6622
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY: 6CENSUS: 2DATE:
07/03/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Administrator, Aidan HaganTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Janira Arreola conducted an unannounced Case Management Visit. LPA met with Administrator, Armond Hagan, who was informed of the purpose of the visit. LPA later met with Staff, Aidan Hagan. LPA made (3) attempts to contact the licensee during the time of the visit, however no response was received. LPA conducted a walk through, interviews, and records review.

LPA conducted a health and safety check on the resident's at the time of the visit. LPA observed (2) residents in care and (2) cleared staff present at the time of the visit. No immediate health or safety issues were observed.

A file review revealed annual conducted on 02/22/2024, and continued on 02/26/2024 had uncleared deficiencies that were verified at the time of the visit. Citation for uncleared adults observed 02/22/2024 was issued. During today's visit LPA did not observed any uncleared adults in the facility, therefore the deficiency was cleared.

Deficiency was issued for medications that did not have a stop of discontinuation order on file for the resident. LPA reviewed the medications during the time of the visit and found all medications accounted for with doctor's orders and on medications lists. Therefore, this deficiency was also cleared at the time of the visit.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 07/03/2025 03:26 PM - It Cannot Be Edited


Created By: Janira Arreola On 07/03/2025 at 01:08 PM
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'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCII
FACILITY NUMBER: 336423972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2025
Section Cited
CCR
87411(c)(1)

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87411 Personnel Requirements - General (c) All RCFE staff...(1)...providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross. This requirement was not met as evidenced by:
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The administrator agreed to obatin training for the licensee and staff and send proof by the POC due date.
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Based on interview the licensee (prior administrator) and (1) current staff do not have CPR and first aid training. This poses a potential health saftey or personal rights risk.
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Type B
07/10/2025
Section Cited
CCR87412(f)

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(f)...personnel, including the licensee and administrator, shall be...physically and mentally capable of performing assigned tasks. Good physical health shall be verified by a health screening...performed by a physician... A report shall be...signed by the examining physician...This requirement is not met as evidenced by:
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The administrator agreed to submit a signed copy of a LIC503 conducted by a physician and submit proof by the POC due date.
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Based on interview and record review, the licensee (prior administrator) did not have a health screening on file to review during the visit. This poses a potential health safety or personal rights risk to residents 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 03:26 PM - It Cannot Be Edited


Created By: Janira Arreola On 07/03/2025 at 01:22 PM
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'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCII
FACILITY NUMBER: 336423972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/04/2025
Section Cited
HSC
1569.605

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On and after July 1, 2015, all residential care facilities for the elderly...shall maintain liability insurance covering injury to residents and guests in the amount of at least one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) in the total annual aggregate...This requirement is not met as evidenced by:
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The administrator agreed to submit proof of liability insurance by the POC due date.
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Based on interview and record review, the facility did not have proof of liability insurance to inspect during the visit. This poses an immediate health saftey or personal rights risk to residents in care.
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Type B
07/10/2025
Section Cited
HSC1569.695(a)

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§1569.695 Emergency Plans (a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following: This requirment was not met as evidenced by:
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The administrator agreed to submit an updated LIC610 in complaince with the section cited by the POC due date.
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Based on interview and record review, the emergency plan does not include the requirements in HSC 1569.695 and needs to be updated. This poses a potential health safety or personal rights risk to residents 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/03/2025 03:26 PM - It Cannot Be Edited


Created By: Janira Arreola On 07/03/2025 at 01:29 PM
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'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCII
FACILITY NUMBER: 336423972

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/03/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/10/2025
Section Cited
HSC
1569.695(c)

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§1569.695 Emergency Plans (c) A facility shall conduct a drill at least quarterly for each shift...Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. This requirment was not met as evidenced by:
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The administrator agreed to conducted and document an emergency drill and submit proof by the POC due date.
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Based on interview and record review the facility did not conduct a quarterly fire drill. This poses a potential health saftey or personal rights risk to residents 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.
Anthony Perez
NAME OF LICENSING PROGRAM MANAGER:
Janira Arreola
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/03/2025


LIC809 (FAS) - (06/04)
Page: 5 of 6
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
FACILITY NAME: WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCII
FACILITY NUMBER: 336423972
VISIT DATE: 07/03/2025
NARRATIVE
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Deficiency was cited for medications being stored in weekly pill boxes and outside their originally received containers. During today's visit LPA observed the resident medications in their originally received containers. Therefore the deficiency was cleared.

Deficiency was issued for the prior administrator and licensee Jacqueline White not having their CPR and first aid certification available for review. LPA reviewed the file for the licensee and found no CPR certificate on file. Therefore a deficiency was issued.

Deficiency was issued for LIC503 Health Screening and TB test for the previous administrator and licensee, Jacqueline White. LPA requested the file for the licensee and found no LIC503 documented for the licensee. Therefore a deficiency was issued.

Deficiency was issued for the facility not having a copy of their currently liability insurance. During the visit LPA requested a copy of the facility's liability insurance and found no liability available for review at the time of the visit. Therefore a deficiency was issued.

Deficiency was cited for the facility not having an emergency and disaster plan on file. During the visit the LPA reviewed the facility's emergency and disaster plan which revealed the plan did not meet the Title 22 requirements. The licensee must update the plan. New deficiency was cited for the licensee to update the emergency plan.

Deficiency was cited for the facility not conducted a quarterly fire drill. during the visit LPA reviewed the last fire drill and found no documented fire drill at the time of the visit. Therefore a deficiency was issued.

An exit interview was conducted with staff, Aidan Hagan where this report and deficiency pages, and appeal rights were reviewed and provided. *LPA was off site from 12:05pm to 1:49pm in order to prepare today's report.

NAME OF LICENSING PROGRAM MANAGER: Anthony Perez
NAME OF LICENSING PROGRAM ANALYST: Janira Arreola
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/03/2025
LIC809 (FAS) - (06/04)
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