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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 336423972
Report Date: 07/26/2025
Date Signed: 07/26/2025 11:53:49 AM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 18-AS-20220803103955
FACILITY NAME:WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCIIFACILITY NUMBER:
336423972
ADMINISTRATOR:JACQUELYN J. WHITEFACILITY TYPE:
740
ADDRESS:24068 RISTRAS LANETELEPHONE:
(951) 319-6622
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 2DATE:
07/26/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Armond Hagan, Administrator TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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The facility is without water service.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Emily Peraldi conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Peraldi met with Administrator, Armond Hagan and explained the reason for the visit.

On 08/03/2022, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding an allegation that the facility was without water service. The complaint alleged that due to non-payment, the facility water was turned off 08/01/2022.


Continued on LIC 9099-C.


Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 18-AS-20220803103955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/26/2025
NARRATIVE
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On 08/04/2022, from 12:05pm to 2:05pm, Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA Delgado met with the Administrator Jacquelyn White and explained the purpose of the visit. During the visit, the LPA toured the facility, verified running water, interviewed one staff and five residents, and requested and obtained copies of pertinent documentation. The LPA determined further investigation was needed prior to issuing findings.

The Department’s investigation revealed that on 08/02/2022 at 4:30pm, it was reported that a hospice staff could not give a bed bath to Resident #1 (R1) because there was no running water in the home. At 6:15pm, the Long-Term Care Ombudsman (LTCO) visited the facility and verified that there was no running water in the house. Staff #1 (S1) stated the Administrator’s husband was on his way to the water company to pay the bill. The LTCO called the Administrator’s husband who confirmed he was trying to get the payment taken care of by water company. The LTCO asked him to purchase extra water to ensure all five residents had enough water for toileting, bathing, cooking of food, drinking and emergencies. The Administrator’s husband stated he would purchase extra water, and that the water service should be back on that night. S1 texted the LTCO at 7:10pm and stated that running water was not turned back on, but the Administrator’s husband had purchased extra water for the home.

On 08/03/2022, the LTCO visited the facility at 9:45am and inquired if the water was turned back on. The Administrator stated the water had not been turned back on and they were calling the water company. The LTCO called the facility at 6:33pm and spoke with the Administrator who stated the water was still not turned back on. The Administrator confirmed that she was using extra water purchased for the residents, still no running water in the home. On 08/04/2022, while conducting the initial complaint visit, LPA Delgado verified the facility had running water.

Based on the Department’s investigation, the licensee failed to pay the water bill which resulted in the water service being turned off. Interviews with the Administrator, Administrator’s husband, and S1 confirmed the facility was temporarily without water service due to non-payment. Therefore, the allegation is deemed Substantiated at this time.

Pursuant to Title 22, California Code of Regulations, the following deficiency is cited (refer to LIC9099-D).
Exit interview conducted, appeal rights discussed, and a copy of this report issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025
LIC9099 (FAS) - (06/04)
Page: 2 of 5
Control Number 18-AS-20220803103955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/26/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
07/26/2025
Section Cited
CCR
87468.1(a)(2)
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87468.1(a)(2) Personal Rights of Residents...(a)Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful...This requirement is not met as evidenced by:
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The licensee submitted payment for the water bill, and water service to the facility was restored. POC cleared.
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Based on interviews, the licensee did not comply with the section cited above when the facility’s water service was turned off due to non-payment of the utility bill, which posed an immediate health and safety 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.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025
LIC9099 (FAS) - (06/04)
Page: 3 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
RIVERSIDE ASC, 1650 SPRUCE ST STE 200 MS29-27
RIVERSIDE, CA 92507
This is an official report of an unannounced visit/investigation of a complaint received in our office on
08/03/2022 and conducted by Evaluator Emily Peraldi
COMPLAINT CONTROL NUMBER: 18-AS-20220803103955

FACILITY NAME:WHITE'S LOVE & CARE RESIDENTIAL ELDERLY HOME INCIIFACILITY NUMBER:
336423972
ADMINISTRATOR:JACQUELYN J. WHITEFACILITY TYPE:
740
ADDRESS:24068 RISTRAS LANETELEPHONE:
(951) 319-6622
CITY:MURRIETASTATE: CAZIP CODE:
92562
CAPACITY:6CENSUS: 2DATE:
07/26/2025
UNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Armond Hagan, Administrator TIME COMPLETED:
12:00 PM
ALLEGATION(S):
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Residents are not being provided with medication as prescribed.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) conducted a subsequent complaint visit to deliver final findings for the above allegation. During today’s visit, LPA Peraldi met with Administrator, Armond Hagan and explained the reason for the visit.

On 08/03/2022, the Riverside Adult and Senior Care Regional Office (RO) received a complaint regarding an allegation that residents were not being provided with medication as prescribed. The complaint alleged that Resident #1 (R1) did not receive their antibiotic due to the Administrator being unable to locate the medication.


Continued on LIC 9099-C.
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 18-AS-20220803103955
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: 07/26/2025
NARRATIVE
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On 08/04/2022, from 12:05pm to 2:05pm, Licensing Program Analyst (LPA) Yolanda Delgado conducted an unannounced visit to the facility to initiate the investigation into the allegation listed above. LPA Delgado met with the Administrator Jacquelyn White and explained the purpose of the visit. During the visit, the LPA toured the facility, verified running water, interviewed one staff and five residents, and requested and obtained copies of pertinent documentation. The LPA determined further investigation was needed prior to issuing findings.

The Department requested copies of R1’s records including Centrally Stored Medication Record (CSMR), Medication Assistance Record (MAR), Hospice Care Plan, and Physician Report. None of the records were provided to the Department. The Department left several messages requesting the documents and additional information, however, no response was received from the facility.

Interviews conducted revealed Staff #1 (S1) stated that the medications were given as prescribed and documented on the MAR. However that information conflicts with concerns found through other interviews where the medication was observed to not be stored in original containers and it was questionable if medication was given as prescribed due to disorganization of the medication administration procedure.

Due to no records being made available to review, the Department was unable to find sufficient evidence to prove R1’s medications were not given as prescribed. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview conducted, copy of this report issued.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 07/26/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2025
LIC9099 (FAS) - (06/04)
Page: 5 of 5